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Posts Tagged ‘c-section’

I’m going to get a bit political today. If you’re not into that, skip this post. There is so much going on about healthcare reform in the media and I can’t help but notice there isn’t much mention of improving the sorry state of pregnancy-related care and maternal/fetal outcomes. No one is talking about the continued restriction of valid childbirth options for women with a history of c-section. Yes, I’m talking about VBAC.

VBAC, short for vaginal birth after cesarean, is a valid healthcare option for pregnant women in low risk categories. According to Childbirth Connection.org:

If you do not have a clear and compelling need for a cesarean in the present pregnancy, having a VBAC rather than a repeat c-section is likely to be:

  • safer for you in this pregnancy
  • far safer for you and your babies in any future pregnancies”

Most OB’s and hospitals that refuse to support VBAC do so citing concerns about uterine rupture. And while this is a possibility, educating women about risks and benefits is vital to informed consent of patients. To be vital, informed consent requires patients (in this case women) the option of informed refusal. It is the right of every person to make healthcare decisions personally. Each pregnant woman, therefore, should also have the same right to choose what she will and will not accept as part of her individualized care. She can choose to accept or refuse induction, epidural, ultrasound, fetal monitoring, IV. She has the right to change her mind, even during labor.

Let’s look at the risks associated with uterine rupture during VBAC (from this article at ChildbirthConnection.org):

“What is the added likelihood that the scar will give way (uterine rupture) during a VBAC labor?
Best research suggests that an extra 27 women experience a ruptured uterus in every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, nearly 400 women would need to experience surgical birth to prevent one instance of uterine rupture during VBAC labors. While the scar giving way usually requires an urgent cesarean, loss of the baby is much less common (see next paragraph).
Added likelihood for a woman with a known low-transverse (horizontal) scar: MODERATE for scar rupture compared with planned repeat c-section.”

“What is the added likelihood that the baby will die as a result of the scar giving way (uterine rupture) during a VBAC labor?

Best research suggests that about 1.4 extra babies die due to problems with the scar in every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, over 7,000 women would need to experience risks of surgical birth to prevent the death of 1 baby from scar problems during VBAC.
Added likelihood for a woman with a known low-transverse (horizontal) scar: LOW for death of the baby around the time of birth compared with repeat c-section.”

To fully understand the risks associated with VBAC and make an informed decision women must also comprehend the risks to mother and baby for repeat cesarean birth. (From this article at ChildbirthConnection.org)

“Extra risks associated with cesarean section: Current research suggests that cesarean section has the following disadvantages in comparison with vaginal birth:

Physical problems in mothers: Compared with vaginal birth, cesarean section increases a woman’s risk for a number of physical problems. These range from less common but potentially life-threatening problems, including hemorrhage (severe bleeding), blood clots, and bowel obstruction, to much more common concerns such as longer-lasting and more severe pain and infection. Even after recovery from surgery, scarring and adhesion tissue increase risk for ongoing pelvic pain and for twisted bowel.

Hospitalization of mothers: If a woman has a cesarean, she is more likely to stay in the hospital longer and is at greater risk of being re-hospitalized.

Emotional well-being of mothers: A woman who has a cesarean section may be at greater risk for poorer overall mental health and some emotional problems. She is also more likely to rate her birth experience poorer than a woman who has had a vaginal birth. {Note: This risk is reduced somewhat for planned cesarean birth.}

Early contact with, feelings toward babies: A woman who has a cesarean usually has less early contact with her baby and is more likely to have initial negative feelings about her baby.

Breastfeeding: Recovery from surgery poses challenges for getting breastfeeding under way, and a baby who was born by cesarean is less likely to be breastfed and get the benefits of breastfeeding.

Health of babies: Babies born by cesarean are more likely to:

  • be cut during the surgery (usually minor)
  • have breathing difficulties around the time of birth
  • experience asthma in childhood and in adulthood.

Future reproductive problems for mothers: A cesarean section in this pregnancy puts a woman at risk for future reproductive problems in comparison with a woman who has a vaginal birth. These problems may involve serious complications and medical emergencies. The likelihood of experiencing some of these conditions goes up sharply as the number of previous cesareans increases. These problems include:

  • ectopic pregnancy: pregnancies that develop outside her uterus or within the scar
  • reduced fertility, due to either less ability to become pregnant again or less desire to do so
  • placenta previa: the placenta attaches near or over the opening to her cervix
  • placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus
  • placental abruption: the placenta detaches from the uterus before the baby is born
  • rupture of the uterus: the uterine scar gives way during pregnancy or labor.

Concerns about babies in future pregnancies: A cesarean section in this pregnancy can affect the babies of future pregnancies. Studies have found that they are more likely to:

  • be born too early (preterm)
  • weigh less than they should (low birthweight)
  • have a physical abnormality or injury to their brain or spinal cord
  • die before or shortly after the birth”

When women are fully informed of the risks associated with repeat cesarean and VBAC, they should each have the opportunity to choose which risks they are willing to take. When a doctor refuses to “allow” his patients to attempt VBAC, s/he is taking away a fundamental right of women to determine the direction of their healthcare.

According to ACOG’s Committee Opinion #321 from November 2005, respecting patient’s autonomous decision making is a fundamental ethical obligation:

“Requiring informed consent is an expression of respect for the patient as a person; it particularly respects a patient’s moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities, and to the support of the patient’s freedom within caring relationships.”

“The ethical requirement for informed consent need not conflict with physicians’ overall ethical obligation to a principle of beneficence; that is, every effort should be made to incorporate a commitment to informed consent within a commitment to provide medical benefit to patients and thus respect them as whole and embodied persons.”

“[Even if] a woman’s autonomous decision [seems] not to promote beneficence-based obligations (of the woman or the physician) to the fetus, … the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the atient’s wishes, regardless of the consequences.“(emphasis mine)

“The obstetrician must keep in mind that medical knowledge has limitations and medical judgment is fallible” and should therefore take great care “to present a balanced evaluation of the expected outcomes for both [the woman and the fetus].”

So how can it be true that women have the right to make autonomous choices regarding their healthcare, including care during pregnancy and childbirth, yet doctors choose to ignore and even ban valid healthcare options for these same women?

This is about women’s rights. A woman doesn’t stop having the right to bodily integrity because she is pregnant. She maintains the right to independent thinking, personal preference, and choice throughout the 40+ weeks gestation. Choosing to bring a child into the world doesn’t limit my right to individualized care or informed consent. In fact, choosing to bring a life through my body has made me more focused on what is appropriate and acceptable risk to me and my baby- and this is a very personal choice.

I should always have the final say about what is ok and not ok for my body, and any baby residing within it. And that’s what I teach my girls.

Who does your body belong to?

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I’ve mentioned before my own ignorance about transformation and c-section. So having come out of that tunnel vision still leaves me with the feeling that the basic system of maternity care doesn’t really support women to healthy birth.

Next week, I’m interviewing an OBGYN on my radio show. He’s very receptive to different ideas, although it’s clear he is a conventional doctor, with beliefs common to the medical profession. I contacted him after reading his blog where he was writing about the causes of escalating rates of cesarean section. He thinks this is a problem (that’s a good start) and he names his opinions for the cause of the 31.8% rate. I think he’s wrong about some of it. But I’m listening because he is looking- and so many doctors aren’t.

(Here is why I am impressed with him: He is open-minded. Although he stated that he believes hospital birth is safer than homebirth, he was willing to consider his opinion might not be fact, but just perception, based on his only experience with homebirth: hospital transfer when it doesn’t work out. When we talked about that, he admitted that this might affect his perception of the safety of homebirth despite statistics- that it is tough to wrap your mind around something that doesn’t reflect what YOU SEE firsthand. He doesn’t see the successful homebirth stories. It takes more effort to be open when what you see doesn’t match the studies.)

So, I’ve been brushing up on my own research and reading what the data shows are the main culprits. We’re going to hash some of it out on the show. But it’s only an hour long show. I know we won’t cover everything because this could be month-long conversation if we had the time. So I want to list on the blog what you can do to lower your risk of surgical birth if you are pregnant.

1. Carefully choose your care provider. Make sure you feel like a partner in your care, that you feel comfortable asking questions, and that your care provider listens to and respects your values, needs and goals.

2. Ask questions about cesarean section well in advance of your labor. Ask for examples/reasons your provider might suggest surgery. Ask what happens if a situation came up where you disagree and refuse surgery or want a second opinion. Ask for examples of non-urgent situations/health concerns that might increase your risk of cesarean. The more prepared you are, the less likely you will feel pushed into something/out of control/dis-empowered if you really do need a c-section.

3. If a c-section is recommended, ask questions: specifically why it is recommended; what benefits it is expected to offer; whether the expected benefit is greater than the risks associated with major abdominal surgery; and what other options exist for your situation. You have the right to this information as part of your right to informed consent. If you are not in labor when surgery is recommended, consider a second opinion, and definitely do some research about the condition or issue cited as the reason.

4. If you’ve already had a c-section, ask for a VBAC. If your doctor/provider does not provide this service, it is important they understand the demand is still there. Consider contacting another care provider if VBAC is important to you. I also recently discovered a doc who was willing to travel to provide VBAC to women in areas it is not available in hospitals.

5. Educate yourself about common reasons given for c-section.

a. Failure to progress– ways to overcome/avoid:

  • Ask your provider in advance: how long is too long? so you can see if this idea/perception fits your individual needs.
  • Move around during labor. Ask in advance about your freedom of movement during labor at your chosen birth location.
  • Avoid interventions (like epidurals) that prevent you from standing/walking around to keep labor moving.
  • Wait to go to the hospital/birth center until you are in active labor (having trouble concentrating or focusing during contractions).
  • Eat during labor- keep up your energy during this “endurance challenge” so you can get to the end. You don’t run a marathon without eating and labor is like a marathon. Ask in advance about the “rules” and about informed refusal of any “rules” that prevent you from eating when you are hungry. (Then be sure to bring your own food with you!!)
  • Hire a doula for personal support and help trusting your body.

b. Changes/concern about fetal heart rate.

  • Ask for intermittent (rather than constant) fetal heart rate monitoring. Shown to be just as effective when used by diligent care providers, it also allows you more freedom to move. (Care providers can listen with a Doppler Device from anywhere in the room.)
  • Attempt to avoid synthetic oxytocin (like Pitocin) which causes more intense uterine contractions and may affect the baby’s heart rate.
  • Ask in advance about options for additional testing to check on the baby if there is concern about heart rates.
  • Ask about moving to a different position and checking the heart tones again if there is concern.

c. Breech position

  • Ask about options for turning a breech baby, including acupuncture, acupressure, breech tilt, external cephalic version (with an experienced provider- ask your provider about their experience. You may consider consulting someone with more experience for this aspect of your care if your provider is not familiar or has limited experience).
  • In my opinion, the safety of vaginal breech birth is largely dependent on the skill and experience of your care provider- so ask at the beginning of your relationship about their experience with this and willingness to offer vaginal birth as an option for a breech presentation.

6. Avoid Elective Induction of Labor

  • Except in the case of maternal health conditions (i.e. diabetes, preeclampsia, unterine infection) or when baby is not growing normally, reasons for induction of labor are generally not medical. Ask your provider why induction is suggested; ask about the risks/benefits of waiting for labor to begin naturally; research on your own the risks/benefits mentioned by your provider.
  • Know that if your cervix is “unripe” (long and closed) you are at increased risk of a failed induction, followed by c-section.
  • Know that medications to “ripen” your cervix (like misoprostol/prostaglandin E1/Cytotec) used during an induction are not FDA approved and may seriously harm you or your baby. There has been no safety testing and there is reason to be concerned. Ask your provider about the medications he/she plans to use and do your own research before you consent.
  • Risk of a “big” baby: Only 30% of pregnant women believed to be carrying a big (over 8lbs13oz) baby actually give birth to a big baby. Ask your provider about risks/benefits. (I was told “they don’t grow more bones in the last 2 weeks, just more fat” and fat is squishy.)
  • Post-term pregnancy (past 42 weeks): When calculating due dates, there is a 2 week margin of error (Lamaze International), so talk to your provider about options to delay/prevent induction, such as monitoring baby 2x per week, amniotic fluid level checks, etc.
  • When water breaks but no contractions (PROM): Ask about waiting for labor to begin spontaniously, discussing/watching for symptoms of infection.

7. Choose a midwife for your care. Women who choose midwifery care have lower rates of cesarean section and higher rates of satisfaction. I’m not saying doctors are “bad.” In fact most are fabulous people. But outcomes are better for mothers and babies when women choose care from a midwife (Coalition for Improving Maternity Services http://www.motherfriendly.org). Reasons women under midwifery care have lower c-section rates seems to relate to the care choices- less use of induction, intermittent monitoring of fetal heart rate, encouraged freedom of movement, women encouraged to eat during labor, less need/use of pain medication. So the methods that get the best results could certainly be employed by doctors too.

I’m NOT anti-doctor. Doctors are needed for women with high risk pregnancies and for emergencies- definitely. Having a care provider who understands you are an individual, that one size doesn’t fit all (or if it does, it is a hand-off approach), who is receptive to questions & takes time to answer them- ALL of THEM, is more important than the title of the professional you choose.

If you want to lower your risk for cesarean surgery, you have to educate yourself and be prepared to ask a lot of questions. If you made it to the end, congrats. Please comment and add your thoughts to the equation.

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