Googling stuff on your smartphone can be a great way of quickly finding out interesting facts. However, it’s not a great method for finding out the risks and benefits of a procedure in the middle of labor. Even if you are planning to have a completely natural birth, it’s a really good idea to know about the different procedures you may have to make a decision about. So to get you started, here is a brief intro to procedures that most low-risk women probably won’t need during labor.
Labor and birth on back– Imagine you’re heading out on a long hike up a big mountain with a backpack filled with useful equipment like snacks, water, a first-aid kit and a rain jacket. The pack is definitely heavy, but manageable. Now imagine that someone adds several large stones to your filled backpack. Hiking that mountain is going to be a lot harder. That’s what labor and birth are like lying down. Midwives and natural birth oriented obstetricians like Dr. Michel Odent and the late Dr. Bradley have been big advocates of upright birth for a long time. Women birthing on their backs or in a semi-recumbent hospital bed position actually has nothing to do with safety or biology, but caught on among obstetricians in the United States during the 19th century because the position was more convenient for them to use forceps during the delivery. A little research that has been done has shown a decreased use of forceps and a decrease in severe tears in women who give birth in a squatting position. On the other hand, if you are more comfortable delivering in a lying down or semi-recumbent position, more power to you. (A great example is actually Cindy Crawford in her interview for More Business of Being Born).
Induction/augmentation– Here’s the thing, the pregnant woman’s body is designed to keep the baby in until the baby is ready to come out. Your baby and your uterus are on their own timetable that doesn’t necessarily coincide with a doctor’s. Also, a woman’s body releases catecholamines during labor if the woman feels threatened. This pauses labor so the woman can escape from the threat. So when we hear about “failure to progress”, “stalled labor” or other terminology, it may have more to do with the environment at the birthing place or an unrealistic timetable than something being “wrong” with the mother, the baby or the labor. Induction of labor increases the risk of c-section, premature birth, uterine rupture, infection, low heart rate, umbilical cord prolapse, and postpartum hemorrhage. Ideally, OB-GYN’s would take the advice of the late Dr. Bradley: “As my chief pointed out, ‘An obstetrician should have a big rear end and the good sense to sit calmly thereupon and let nature take its course.”
Cesarean- My husband is here today because his mother was able to have an emergency cesarean for placenta previa with his older sister. What I’m talking about here are unnecessary cesareans- which are actually a very real public health issue. As many of you have heard, almost one-third of all babies in the United States are delivered through Cesarean section. However, according to WHO, cesarean surgery is medically indicated in only about 10%-15% of deliveries. In fact, OB-GYN’s often perform cesareans simply because they don’t want to wait around for a mother to deliver vaginally and believe it to be a low-risk procedure. Some have tried to claim that cesarean birth is safer than vaginal birth, however research does not bear that out as certain types of serious birth injuries are the same for planned cesareans or vaginal births. Other scholars have tried saying that the WHO’s upper threshold of 10-15% cesarean rate should be increased to 20%, however, this does not account for the increased public health costs of cesareans, which include higher financial costs associated with Medicaid, less breastfeeding, much higher respiratory morbidity for infants and frequent injuries to mother’s internal organs resulting from cesarean surgery. For a full explanation of how high cesarean rates impact public health, see my paper posted in three parts starting here.
Amniotomy/ Stripping membranes– From the U.S. National Library of Medicine’s database here is the summary of research on amniotomy: “Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged.” There is really no hard evidence that it actually speeds up labor or strengthens contractions. But it can increase the risk of infection for the mother and baby.
Pain medication- Well, this is one of those touchy subjects. But technically most of us don’t need pain medication for labor. Believe me, when you’re having a painful labor it’s not fun. (You should have heard me a few weeks ago during my last labor. “It huuuuurrrrts!”) But having pain medication for a normal labor (spontaneous and without serious complications) won’t make the labor any safer. There are many mothers who report positive experiences with pain medication during labor. However, like any medication, parents need to be aware of the both the benefits and risks as well as the alternatives- and pain medications do have risks. According to the American Congress of Obstetricians and Gynecologists, pain medications in labor can cause side effects like nausea, feeling drowsy, or having trouble concentrating. They can affect the baby’s heart rate temporarily. It can be more difficult to detect fetal heart rate problems when these drugs are used. High doses of these drugs can cause the mother to have breathing problems and can also slow down the baby’s respiratory system, especially right after delivery. Other complications can include: Decrease in blood pressure which can slow the baby’s heartbeat, fever, headache, and soreness. Serious complications with epidurals are very rare but can include: anesthetic medication being injected into one of the veins in the epidural space causing dizziness, rapid heartbeat, a funny taste, or numbness around the mouth. There are a number of different approaches for managing pain in labor that don’t involve medication including water birth with a qualified attendant, hypnobirthing and changing positions.
Episiotomy- Once upon a time, doctors thought that performing an episiotomy (a surgical cut made to the perineum) would prevent extensive vaginal tearing and heal faster than a tear. Turns out neither of those is true. The Mayo Clinic says that there are certain circumstances when an episiotomy might be recommended such as when extensive vaginal tearing appears likely, the baby is in an abnormal position, the baby is large (fetal macrosomia), or the baby needs to be delivered quickly. However, getting out of the lithotomy position can be very helpful in preventing or minimizing tearing in many of these circumstances.
Continuous Electronic Fetal Monitoring- Maybe you’ve heard that continuous electric fetal monitoring prevents babies from dying or being brain damaged during birth- but that’s only been shown to be the case for high risk pregnancies with conditions like preeclampsia, type 1 diabetes, preterm birth and suspected intrauterine growth restriction
If you’re low-risk, continuous EFM doesn’t have any proven benefits and has a significant increase in the risk of cesarean and instrumental deliveries and maternal infection. In fact, the American Congress of Obstetricians and Gynecologists has stated that for low-risk pregnancies there are no proven benefits of EFM over intermittent ausculation. (Intermittent ausculation is the form of fetal monitoring used by midwives who attend home births. It involves using a Doppler fetal heart monitor to check the heart rate every few contractions. It allows midwives to easily check heart rate when the mother is in different positions and even underwater in a water labor/birth.) So why do doctors and nurses persist in using continuous EFM as a one-size fits all solution? Well… it is easier on the nurses, especially when there is central fetal monitoring where the readings from several EFM machines can be observed from the nurses’ station. Intermittent ausculation requires more individualized attention. Doctors are frequently worried about liability and the possibility of being sued for not using it, even though there isn’t any evidence backing up this belief either.
Forceps- Well, by now you should probably be seeing a pattern: certain practices like the lithotomy position or continuous EFM for low-risk women lead to more instrumental deliveries. So if you’re low-risk and stay off your back and have intermittent ausculation during labor, you’re much less likely to end up with a forceps delivery. Which is a good thing since forceps delivery carries an increased risk of uterine rupture, injury to the mother’s bowel and bladder and injury to the perineum. The baby is at an increased risk for temporary facial paralysis, skull fracture, seizures and hemorrhage in the skull. All that being said, forceps may pose less of a risk of seizures for babies than delivery with vacuum extractor or c-section.
As I’ve been doing my observation to become a childbirth educator, I’ve noticed a very interesting phenomenon. I’ve been hearing a lot of doulas and CBE’s warn against the perils of people “helping” in the first few days after the baby is born. Their advice was to keep visitors out for the first few days and allow the parents and baby to recover from the birth.
It was a little surprising. I had heard some horror stories about “helpful” relatives and neighbors after the baby comes. Sometimes people come over to help but just want to see and hold the new baby right away at the expense of the new parents’ bonding or rest time, or someone who decides to do laundry without asking about any special instructions and ruins an entire supply of cloth diapers, or a relative comes over and feeds the older children junk food against the mother’s wishes… But despite these kinds of stories, most of the time I had heard that parents should gratefully accept any offers of help after their baby arrives.
And on the other hand, I’ve heard of many women who have mothers, neighbors or good friends who are willing to help out around the house or take older children for outings right after the new baby is born. (In twenty years I want to be one of those mothers/mothers-in-law.)
But should new parents simply be grateful for everyone who shows up at their door- even if the helper actually causes more trouble than help? Is it really “the thought that counts”?
There is a fantastic article from the December 1990 issue of the LDS magazine Ensign called “Caught in a Casserole” by Joni Winn Hilton. She starts off by describing an incident that had happened in her neighborhood some time before. A Vietnamese had family moved in, leaving everything behind in their homeland to start a new life in a new country. The neighbors responded by bringing over pies and casseroles and offering odd jobs to the father and left feeling very satisfied with themselves for their generosity.
But for the Vietnamese family, it was the opposite of what they needed. They had never eaten American food and the father was a highly educated professional in his native country, not some skill-less itinerant. Sure, it was a convenient way for the neighbors to check something off their to-do list and pat themselves on the back, but it wasn’t what the family needed.
I experienced something similar after births of my first two boys. When our oldest was born, he required specialized care at a high level NICU where there was no rooming in available. Fortunately, we lived relatively close to the hospital, so my husband and I spent most of our time with our new baby at the NICU for the first couple of weeks of parenthood learning how to take care of his condition and meeting with a slew of specialists. We were getting about five hours of sleep each night. We lived off of a morning green smoothie, apples, trail mix and chips and crackers from Whole Foods. We ate most of our meals in the car.
We had changed our diet some time before, finding that cutting out dairy for my husband and most gluten for me helped with a number of health issues we had had. Since we no longer ate the same way the other people in church group did, they tried to help by bringing meals by for my husband’s parents who we were residing with at the time. My mother-in-law said she didn’t need the food, but she went with it anyway. Since it had gluten and dairy in it and we were already in high stress circumstances, we didn’t want to risk eating anything that could upset the already delicate balance we were trying to maintain physically, mentally and emotionally.
With our second baby, we were still living in the same area with the same church group and what we really needed were meals. We now had a special needs child on top of a newborn. We didn’t have much help and were pretty busy as my husband tried to take care of our oldest while cooking meals for the first few days and I kept up with the laundry from the day of the birth onwards.
One thing we did have plenty of though, was baby blankets.We had received a number of lovely baby blankets as gifts with our oldest, some of which had become very special, but now that he was older and no longer needed them they were perfectly suited to our second baby. Because some of the blankets had deep meaning to us in seeing our first through his NICU stay, we weren’t inclined to give them away. However, this time the church group brought us baby blankets. Lots of baby blankets. In addition to the half dozen or so baby blankets we already had, we got three or four new ones. We ended up donating the new ones because we simply couldn’t use them and didn’t want to give away the special ones. But we hoped someone else might benefit from them. It’s really difficult to make a meal out of a baby blanket. (But if you ever come up with any good recipes, be sure to let me know.)
This kind of phenomenon is not exclusive to neighbors though. I’ve been taking a class for my MPH in disaster relief and emergency management and emergency response personnel frequently deal with the same problem- on a much larger scale. Disaster response organizations have had a difficult time dealing with all the wrong help. In the aftermath of the Haiti earthquake, aid workers kept finding unsolicited volunteers who showed up in Port-au-Prince without even a ride from the airport. Without any purpose for being there beyond “helping” and with no food or supplies of their own, these people often ended up relying on disaster response organizations to provide them without shelter and food- draining resources from the very people they claimed to want to help. Tsunami and hurricane relief workers frequently have to deal with finding a place for unsolicited and useless donations that show up in the wake of a tropical disaster- like evening gowns, cans of expired food, fur coats, stiletto heels, thong panties, housewares and outdated prescriptions.
If you want to really get your humanitarian socks knocked off, watch the recent Oscar winning documentary Poverty, Inc. about how ongoing foreign aid often causes more problems for developing countries than it solves.
And so here comes the question: If we’re giving to make ourselves feel better, but it doesn’t actually help the people we claim to serve, is it really service? Sure, offloading some old stuff or rushing off to Haiti might make you feel good about yourself, but is it what someone else needs? As I look back at the experiences from my postpartum days, it does strike me that no one really bothered to ask what might help us. Looking at everything from the Vietnamese family to the tsunami donations, there are frequently a lot of assumptions that go into service, mostly that we understand the situation and that what would be most convenient for us is helpful for the people we intend to serve.
But there’s one thing I can tell you for sure: PLEASE save your used thong panties and outdated prescriptions and canned goods the next time a tropical storm hits! You can’t go wrong with a good old-fashioned donation to a reputable humanitarian organization. Remember, they buy goods in bulk so even a few dollars can go a long way to providing clean water and medical supplies during a disaster response. =)
It’s a FANTASTIC tradition. After a family is blessed with a new baby, neighbors, friends, and family bring over meals to ease the family’s adjustment. This all used to be fairly straightforward when people tended to eat the same thing. Bring over a casserole/dessert/salad and help out. But now we live in a world where people eat a diversity of diets.
Gluten free, vegetarian, vegan, no artificial dyes or preservatives, free range and hormone/antibiotic free meat and dairy… and the list goes on. Sometimes moms also have to cut out dairy, soy or other foods to safely breastfeed a baby with food sensitivities. Sometimes these changes are beyond even just feeling better, they are lifesaving. If someone in the family is diabetic or has an anaphylactic food allergy, even one meal that deviates from their diet could be life-threatening. This can make it really awkward for both parties to simply bring over a meal. I think there are probably more families than ever in a situation where they have changed dietary habits.
So how do you navigate the tricky waters of bringing meals to families that have different dietary restrictions? Here are a few suggestions- and they work great for many different situations like funerals, illness, holidays or neighbors who have just moved in:
If you’re going to be preparing a meal for them, ask if they have recipes they can share with you. This way, you’ll know they have something they will look forward to eating that will meet their dietary needs. You might even find a new dish to make for dinner too.
Not comfortable actually making a meal? This is totally OK! There are a lot of really good reasons that you may not feel comfortable actually making a meal for someone even though you really want to help. If you have strong feelings about working with animal products, you yourself have food allergies that make it difficult to handle certain types of food or someone in the family has a potentially life-threatening allergy and there are concerns about cross-contamination of food that is brought in. It could also be as simple as geographical distance. Maybe you or the family who is expecting live in another state (or even another country). There are still lots of ways to help:
Offer to pick up some staple items or snacks so that the family will have some extras on hand during the postpartum recovery period. Having good quality food on hand that requires little or no effort and thought to prepare is a lifesaver when a new baby comes- especially if there are older siblings who will need someone to prepare food for them. Nut butter, hummus, bread, tortillas, crackers, cereal and milk substitutes, dried fruits and nuts are a few examples of quick but nutritious foods that can help a lot in the tiring days after a new baby arrives. Ask about specific brands, especially with food allergies. Most families will have some go-to snack items that fit their particular needs. In addition to the local grocery store, you can also order items on Amazon.com, which can be especially nice for multi-packs of certain foods. If you want to get really creative, you could even put together a gift basket or gift box to welcome the new baby.
Gift cards. In my opinion, this is another great option. Ask the parents if there is a particular restaurant or grocery store that they would be nice for picking up a quick healthy meal like Whole Foods, Sprouts, Chipotle, etc. Some restaurants have menu items that fit different diets and allergies and will even have an order online option. Gift cards can be really nice if you want to send something helpful but can’t ship anything perishable because of distance. You can also send an Amazon gift card so the family can stock up favorite staples in bulk packs too.
Is this different than bringing over the traditional dinner? Yes. But especially if you ask the family about their needs and comfort level, it’s not necessarily unwelcome.
“Nana’s and Papa’s- There’s a whole lot of spoiling going on!”- Doormat in a mail order catalogue
“One more no and I’m going to Grandma!”- Onesie in a gift shop window
“If Mom and Dad say no, go to Grandma!”- Bumper sticker on an RV
“Agenda for the day: Sugar the grandkids up and send them home to mom and dad.”- Another door mat
“Grandchildren are the reward you get for not killing your children.” – License plate frame
“A parent’s job is to discipline and critique. A grandparent’s job is to spoil and coddle.”- Facebook meme
…And I could go on and on with examples of paraphernalia extolling the grandparents’ role in spoiling their grandchildren. The idea that parents do the “dirty work” of raising children while grandparents get to do all the fun stuff has definitely taken hold in 21st century America. I have heard some grandparents say that being a grandparent is better than being a parent because you don’t have to do the discipline and diapers and can just have fun spoiling the grandchildren. I have been told to my face that some day, I will be lucky enough to be a grandparent and then I’ll finally be able to have fun.
Sometimes it seems as though I am surrounded by messages that my job as a parent is thankless drudgery and that if I can keep my kids alive and out of jail long enough, one day I will be able to reach a state of nirvana called grandparenthood where I can dole out endless treats and gifts and finally receive some adoration.
But I really have to disagree with this idea of both parenthood and grandparenthood. And I think it hurts everyone involved.
Obviously, this concept of parenthood hurts parents by undermining their authority and demeaning the importance of the role of parents in their children’s lives and society at large. The idea that “if Mom and Dad say no, go to Grandma/Grandpa”, really undermines parents’ authority to raise their children. It’s actually a very subversive idea that the grandparents are entitled to get the last say in what happens to a child based on their desire to win the child’s affections in the moment. In the worst cases, this can turn into a competition of parent and grandparent trying to win over the child. I hear people complain that the Women’s Liberation Movement demeaned motherhood by focusing on how restrictive it is for women and that being a homemaker wastes a woman’s talents, but is the narrative that parenthood in general amounts to “being the bad guy”while Grandma and Grandpa should be the ones to have all the fun really any better?
This mentality also hurts the kids. The kids start thinking of grandparents as vending machines rather than family members. It reinforces the idea that love can be bought. And “spoiling” in the sense of giving children anything they want without regard for rules, boundaries, consequences or behavior is actually extremely hurtful to children. It feels good in the moment, but ultimately it cripples them by giving them an unrealistic view of how life works. The reality check will come some day, and when it does, it will be brutal.
And… it hurts the grandparents too. Really, it does. When you tell someone you’re just there for the good times and don’t want to be bothered with any of the “messy stuff” like reinforcing good behavior or passing on good values, don’t expect them to be ecstatically grateful when you suddenly start doling out unsolicited advice. Also, if the grandparents’ version of “spoiling” leads to too much trouble or undermines the way the parents are trying to bring up the children, the parents may start enacting more supervision on the grandparents as well as the children. Ultimately, children won’t love their grandparents any better if the grandparents hold the children to a low (or no) standard of behavior. And grandparents who dare to tread in that territory can only expect that their grandchildren will return such low standards with disrespect.
I also disagree with the idea that it’s Grandma and Grandpa who should get to have all the fun with the kids. I support healthy intergenerational relationships. We’ve had some especially fun times with my dad taking the boys and my husband and me to airshows, museums and planetariums. (Actually, I really like that my dad likes to hang out with me and my husband and not just our kids.) There’s nothing wrong with the grandparents sending presents for Christmas and birthdays and having special outings with the grandkids. But I also believe that as a parent, that it is my right to judiciously give my children special and fun things and experiences.
We’ve taken our kids to the zoo, park, movies, museums, and made dinner around the campfire singing “Country Roads Take Me Home” in the shadow of the mountains. My husband is a sucker for giving our boys building sets and puzzles which they will delve into with wild abandon. (I found the trick for keeping my blood pressure down when dealing with all the little pieces was to institute a nightly pick-up routine.) I love to make healthy desserts and my boys love to eat them. My husband reads stories every night to the boys before bed.
Yes, we break up fights, change diapers and potty train, face the deluge of bath night, the screams from nail trimming sessions, and answer endless questions from our ultra-inquisitive six year old. And yes, there are days when I want to lock myself in the bathroom and hope that no one will find me while I eat an entire dark chocolate bar and take a long epsom salt bath with lavender essential oil. (That has not happened yet. They always find me. Always. Especially if chocolate is involved.)
But there’s something about all the work that has its rewards. Like when our three year old announced he needed to go potty before he’d actually done anything. We’re talking about moving him into underwear. Underwear! After having a moment straight out of Inside Out where we had to “put the foot down” with our six year old, he is doing his physical therapy exercises pretty consistently and with a good attitude. It’s those moments that make it all worth it. Those are the moments when I think, “Maybe those sixty-something strangers in the grocery store who keep telling us we are good parents are actually right!” I guess you could say that I’m a believer in “no pain, no gain”. I don’t think it’s possible to have a meaningful relationship with a child without enforcing some boundaries and rules.
We really may be the first culture in recorded history to hold that the role of grandparents is to be free from the responsibilities of family and community. Historically, grandparents took on greater responsibilities within their communities as their children grew and “left the nest”. They became the wise women and village elders, passing on traditions and knowledge, mentoring young people as they took on the mantle of parenthood. In fact, anthropologists now think that the rise of grandparents in ancient human populations may have been crucial to humans ability to survive and thrive in the ancient world. The experience of the older generation, such as what plants to eat or avoid and how to find water in a drought would have contributed to the clan’s survival.
It’s also likely that humans’ technological developments such as basket weaving and tool-making were products of the experience that grandparents could pass on to their children and also grandchildren. They could also increase the odds of survival for family members by supplying additional support and help for parents and children in their clans.
Maybe it’s time to kick it old school and return to that model. Get rid of all the cutesie onesies and bumper stickers extolling grandparenthood without any responsibilities. I think we need more mentors, village elders and wise women for our children and less spoiling. After all, imagine what our movies would be like if we expected the same standard from our Jedi masters and starship captains as we currently do from grandparents.
By April 1970 space travel was largely regarded as mundane. Two successful moon landings had taken place and the public had started to view space travel as an endeavor with as much risk as road tripping to see family in Ohio.
For the crew of Apollo 13 though, it was the culmination of years of training. They were all stand out pilots who were excited to have the chance to go to the moon- a genuine, once-in-a-lifetime opportunity. For Commander Jim Lovell, this was the top of pyramid. He had clocked more time in space than almost any other astronaut and had even seen the moon on flyby when he was part of the Apollo 8 crew’s Christmas mission. (You can still see the video coverage where they filmed the Moon from space, reading from the first chapter of Genesis. Whatever your religious views, it will give you chills as you think about just how vast and ancient our universe is.) Lovell had had an incredible career. Apollo 13 was his last mission and visiting the moon was everything he could have wished for as a pilot and astronaut.
The third moon landing mission Apollo 13 launched with little fanfare or attention… until a malfunction left astronauts Jim Lovell, Fred Haise and Jack Swigert stranded in space while NASA engineers worked day and night for almost six days to solve an ever increasing list of problems and bring the astronauts back home safely.
The situation was far from ideal. A routine stir of the oxygen tanks had caused an explosion on the spacecraft leaving the astronauts with no other option than to leave the spacecraft Odyssey (which was meant to ferry the three men to and from the moon) into the lunar landing module or LM (which was designed to carry two of the crew to land on the moon from lunar orbit). With three occupants instead of two, the LM’s carbon dioxide filters quickly started becoming overwhelmed and the filters between the Odyssey and the LM were not interchangeable, so NASA engineers had to figure out how create an adaptor using only the materials the astronauts would have on board.
The LM was not designed for multi-day usage, so they had to turn the power down to an absolute minimum to subsist for the entire journey back to Earth. (For a point of comparison, there is a famous line in the movie where one engineer protests this idea shouting “You can’t run a vacuum cleaner on 12 amps!”) This meant that the onboard guidance computers had to be shut down. It meant turning off the heat so the astronauts were floating around in temperatures as low as 38 degree temperature with no warm clothing. Water had to be rationed to last the entire trip (Fred Haise developed a UTI and subsequent kidney infections during the whole ordeal.) And no waste dumps were allowed for fear it would mess up the already tenuous trajectory of the injured space craft. All human waste was confined to bags and kept in the craft.
The odds were not good. But as lead flight director Gene Kranz would later say, “Failure was not an option.” They refused to let three men die in space and simply kept working problem after problem. After a lot of hard work, courage, and a few lucky breaks (like the onboard computer not shorting out when it was powered for reentry and missing a hurricane at splashdown), the crew of Apollo 13 made it safely home to their families. The mission was considered a successful failure. They failed to reach the moon and none of the crew would ever have the chance to visit the moon again. But despite all the challenges, they made it safely home.
NASA and other space agencies don’t make a habit of pushing spacecraft to work in ways that defy design and specification. It would sure save a lot of power, but turning onboard computers and heating off are not routine because of the risks involved to the astronauts. Nobody wants to make those types of sacrifices unless it’s absolutely necessary. On the other hand, if you ask anyone at NASA who had to live through Apollo 1 (fatal fire during training), Challenger (explosion on the launchpad) or Columbia (disintegration upon reentry), which they would choose, they would take Apollo 13 in a heartbeat. No one wants dead astronauts.
A c-section should be the same way. It’s not ideal. You are surgically cutting open the womb. There is a 12 percent chance of damage to the mother’s internal organs. There is an increased chance of hysterectomy, blood transfusion, uterine infection and future placental abnormalities for the mother. There is a 1.1% chance of some kind of injury to the baby, ranging from minor to serious. The baby is very likely to experience respiratory problems which will require a NICU stay. Breastfeeding is frequently more difficult because of the problems associated with nursing after major surgery. We’re talking about additional risks over a normal, uncomplicated vaginal birth, but when faced with a life and death situation, we all want safe mothers and babies. And if that means the obstetrical equivalent of pulling out a lifeboat in space, turning off the power, and fashioning a carbon dioxide filter adaptor from duct tape, we’re going to do it because it has a good chance of saving lives.
When we talk about c-sections, we’re not talking about a choice between risk and no-risk. C-sections carry additional risks over normal, uncomplicated vaginal birth. The engineers and astronauts realized that every decision they were making about the Apollo 13 mission carried an additional risk of death over an uncomplicated mission, but those risks were worth the chance of bringing the astronauts safely home because they were not dealing with a normal, uncomplicated mission. C-sections should not be seen as a routine procedure. Health professionals, parents and birth workers need to keep in mind that c-sections are the obstetrical equivalent of Apollo 13. If we start confusing “normal” with “emergency” we are creating a situation that exposes mothers and babies to additional risks.
While doctors’ fears seem to be that a lower rate of cesarean surgery will mean greater mortality and morbidity for mothers and babies, the statistics indicate this fear is not well-founded. There really is no data showing that higher cesarean rates equate with lower rates of maternal or neonatal mortality (Lake, 2012). Many circumstances where a cesarean is clearly indicated such as placenta previa or severe preeclampsia should be clear to any competent obstetrician as they will be accompanied by symptoms of a life-threatening emergency like vaginal bleeding and hemorrhage, seizures, blood pressure changes, and vision disturbances. In the case of transverse lie, a simple ultrasound will show the position of the baby. In cases such as maternal infection with HIV or hepatitis B where a cesarean section is indicated to prevent transmission of the infection to the baby, testing can be done to ascertain the mother’s infection status. Other circumstances for a cesarean surgery need to be more clearly outlined by hospitals and even in medical school curriculum and practice.
Helping both doctors and patients understand the actual risks and benefits of a cesarean surgery will be crucial in decreasing the overall rates of cesareans. Patients need to understand that a cesarean section is a major surgery and not a benign procedure. While vaginal birth entails risks, so do cesarean sections and the choice between a vaginal birth and cesarean is not a choice between a dangerous option and a risk free option, but rather weighing the actual risks and benefits in each patient’s specific case.
The risks and benefits of vaginal birth after cesarean may not be fully understood by many women. The risk of uterine rupture is frequently cited as a a reason that a VBAC could be too dangerous, but the actual risk of uterine rupture and even the actual risks to the baby are not necessarily well communicated to mothers. The ACOG’s 2010 bulletin on VBAC shows that the risk of uterine rupture is 0.4 to 0.5 percent for planned, elective cesarean, 0.7 to 0.8 percent for a trial of labor after one cesarean and between 0.9 and 1.8 percent for a trial of labor after two cesareans. Ironically enough, it is statistically more likely that a baby will be injured during a cesarean section than suffer from a uterine rupture- especially with a trial of labor after one cesarean.
ACOG’s 2010 bulletin further explains that many risks associated with VBAC are negligible when compared with those of elective repeat cesarean section. The risk of neonatal death during a trial of labor after cesarean is 0.05 percent for elective cesareans and 0.08 percent for a trial of labor after cesarean (TOLAC). The rate of perinatal death due to hypoxia was greater for TOLAC than elective repeat cesarean mothers at 0.13 percent versus 0.01 percent, though still extremely rare. Helping more women to accurately weigh the risks and benefits for their pregnancy and achieve a successful VBAC will help with reducing cesarean rates and the accompanying costs and risks.
The usage of cesarean surgery has been controversial, but based on data about the risks to mothers and infants and the accompanying costs associated with cesarean rates, it would be in the best interest of women, infants and healthcare costs to reduce the rate of cesarean sections. This will require doctors and expectant parents to adjust some of their perceptions about vaginal birth and cesarean birth, but a reduction in cesarean rates is possible and desirable. Reducing cesarean sections does not have to mean that cesareans are withheld from women who need them or that doctors should be reluctant to perform them when medically indicated. Instead, care should be taken to establish the circumstances when a cesarean is actually necessary and reserve the usage of cesarean surgery for instances when it is truly needed. A cesarean section is major surgery and should never be performed for the comfort and convenience of the physician. Women should also be fully aware of the real risks and benefits when they decide to have an elective cesarean.
Alexander, James M., Leveno, Kevin J., Hauth, John, Landon, Mark B., Thom, Elizabeth, Spong, Catherine Y., Varner, Michael W., Moawad, Atef H., Caritis, Steve N., Harper, Margaret, Wapner, Ronald J., Sorokin, Yoram, Miodovnik, Menachem, O’Sullivan, Mary J., Sibai, Baha M., Langer, Oded, and Gabbe, Steven G. (2006). Fetal Injury Associated with cesarean delivery. American College of Obstetricians and Gynecologists 108(4). Retrieved from http://content.lib.utah.edu/utils/getfile/collection/uspace/id/395/filename/3560.pdf
American College of Obstetricians and Gynecologists (2010). Vaginal birth after previous cesarean delivery. Practice Bulletin- Clinical Management Guidelines for Obstetrician-Gynecologists, no. 115. Retrieved from http://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Obstetrics/Vaginal-Birth-After-Previous-Cesarean-Delivery
Gorman, Anna (2015, May 13). How one hospital reduced unnecessary C-sections. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2015/05/how-one-hospital-reduced-unnecessary-c-sections/392924/
Grivell, Rosalie M. and Dodd, Jodie M. (2011). Short- and long-term outcomes after cesarean section. Expert Review of Obstetrics and Gynecology, 6(2). Retrieved from http://www.medscape.com/viewarticle/739458_1
Harvard School of Public Health (2013, March 19). Pregnant women’s likelihood of cesarean delivery in Massachusetts linked to choice of hospitals. Retrieved from http://www.hsph.harvard.edu/news/press-releases/pregnant-womens-likelihood-of-cesarean-delivery-in-massachusetts-linked-to-choice-of-hospitals/
Kozhimannil, Katy Backes, Law, Michael R. Virnig, Beth A. (2013). Cesarean delivery rates Vary 10-fold among US hospitals; reducing variation may address quality, cost issues. Health Affairs 32(3). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615450/
Lake, Nell (2012, November). Labor, interrupted. Harvard Magazine. Retrieved from http://harvardmagazine.com/2012/11/labor-interrupted
Laroia, Nirupama (2015). Birth trauma. Retrieved from http://emedicine.medscape.com/article/980112-overview#a1
Marasco, Lisa and West, Diana (2005). How to get your milk supply off to a good start. New Beginnings, 22(4). Retrieved from http://www.lalecheleague.org/nb/nbjulaug05p142.html
Stanford University (2015, December 1). Optimal C-section rate may be as high as 19 percent to save lives of mothers and infants. Stanford Medicine News Center. Retrieved from chttps://med.stanford.edu/news/all-news/2015/12/optimal-c-section-rate-may-be-as-high-as-19-percent-to-save-lives.html
Warner, Lawrence W., (2013). Arriving at the appropriate cesarean delivery rate. American Congress of Obstetrician-Gynecologists. Retrieved from http://www.acog.org/About-ACOG/ACOG-Departments/District-Newsletters/District-VIII/July-2013/Cesarean-delivery-rate
Safe delivery of the baby is one of the most common goals in performing a cesarean section, yet cesareans carry additional risks to infants as well. It is well-established that infants born via cesarean section are at a significant risk for all types of respiratory issues than infants delivered vaginally, often necessitating newborn neonatal intensive care unit admission (Dodd and Grivell, 2011). Cesarean surgery can also make it more difficult to establish breastfeeding because it is often impossible or impractical to nurse the infant during the first hour of life due to the challenges of anesthesia and suturing (Marasco and West, 2005). Another risk to infants from cesarean sections that is often not discussed is birth injury. Birth injuries complicate about 6-8 our of every 1,000 deliveries in the United States (.6 to .8 percent) (Laroia and Rosenkrantz, 2015). However, a 2006 report from the American College of Obstetricians and Gynecologists by Alexander, Leveno and Hauth et.al. found that fetal injury occurred at a rate of 1.1 percent for cesarean deliveries- higher than the overall average.
Along with the risks to mothers and babies, there are significant healthcare costs that accompany a high c-section rate. A cesarean section costs $12,739 as opposed to $9,048 for a vaginal birth for private health insurers in 2010. The cost difference for cesarean surgery has significant implications for Medicaid since public insurance pays for about half of all births in the United States. In 2009, Medicaid paid $3 billion for cesarean sections (Kozhimnnil, Law and Virnig, 2003). Along with the costs for cesarean surgery itself, there are also accompanying costs for infections, intraoperative and birth injuries, NICU stays, blood clots and transfusions as well as the increased risk of subsequent cesarean birth. In short, cesarean sections are a very expensive way to give birth.
Hospitals also take on additional costs when their cesarean rates become too high. Hoag Memorial Hospital Presbyterian in Orange County, California was almost dropped by its insurer when its maternity costs became too high from too many c-sections. With an aggressive action plan that monitored doctors’ cesarean rates, decreased financial incentives to perform cesarean surgery and policies that allowed women more time to labor before opting for a cesarean, the hospital administration managed to decrease cesarean deliveries by approximately 5 percent and increase vaginal births after cesarean by 11 percent (Gorman, 2015).
When the choice is between death or serious injury to the mother or baby and a cesarean delivery, then the costs and risks are worth it. But in the majority of cesarean sections, there is no clear indication of imminent harm to the mother and baby. In fact, many of the physicians at Hoag pointed out that cesareans were frequently performed at the hospital because doctors did not want to wait out a labor and a perception among both doctors and patients that a cesarean section was an easy way to time a birth and a relatively harmless procedure (Gorman, 2015). A study from the Harvard School of Public Health found that a hospital’s culture and practices can substantially influence whether a mother ends up having a cesarean section or delivering vaginally. Liability and insurance, being a teaching hospital, hospital admission practices, and the presence of midwives may influence c-section rates as do lack of clinical guidelines or standards on when a cesarean should be performed (Harvard School of Public Health, 2013).
Fear of liability influences the decision to perform a cesarean section for many doctors. The perception that a c-section means the doctor has done everything to intervene and therefore protects him or her from a liability remains a powerful idea and adds significant pressure to many doctors- whether the situation is statistically low-risk or not. Parents are also frequently subject to perception errors in making a decision about birth. Stories from family, friends and the news can weigh more heavily in their decision making process than actual statistics and medical facts about their own situation simply because these isolated incidents carry so much emotional weight (Lake, 2012).
Doctors have been reluctant to talk about actually decreasing cesarean section rates. Dr. W. Lawrence Warner stated in his 2013 article for the ACOG, that “Care must be taken to not have the unintended consequence of physicians becoming reluctant to proceed with clearly indicated cesarean deliveries because they fear criticism after later review of the care by the quality committee.” A 2015 study from Stanford University argues that the World Health Organization’s upper limit for cesareans of 10 to 15 percent should be reexamined and raised to 19 percent. However, while the results from this study argue that there is no additional risk of maternal or neonatal mortality from a 19 percent cesarean rate, they do not address the increased health and financial costs that come from performing cesarean sections that have no clear medical indication.
This is the first part of a paper I wrote for one of my classes on the public health benefits of reducing cesareans. Please feel free to quote from this as long as you give proper attribution to me and the authors of the cited sources of this paper. Thanks and enjoy!
The cesarean section is now the most common surgical procedure in the United States and accounts for 32.8 percent of all deliveries as of 2011 (Kozhimnnil, Law, and Virnig, 2013). This is a substantial increase from what it was decades ago. As Dr. W. Lawrence Warner stated in a 2013 article for the American College of Obstetrics and Gynecology, “When I began medical school in 1970, the overall cesarean delivery rate was 5.5%… I practice in Utah, where the rate is 22.2%, the lowest in the country. In New Jersey, the rate is 38.3%, the highest in the country. There are some individual hospitals with rates well over 50%.”
There are many factors that have been cited as driving the increase in cesarean rates, including an increase in multiple gestations due to fertility treatments, rising rates of maternal obesity and conditions such as gestational diabetes and preeclampsia. However, other issues that are not related to the actual health of the mother or baby also come into play, such as convenience and doctors’ concerns about liability and malpractice (Kozhimnnil, Law, and Virnig, 2013).
Cesarean sections play a vital role in maternal and child health. There are situations which absolutely indicate the use of a cesarean, such as transverse lie, preeclampsia or other hypertensive disorders of pregnancy that have progressed to a life-threatening stage, cord prolapse and placenta previa. However, these cases account for only a small number of c-sections performed, which means that many c-sections are not actually a medical necessity. This has important implications from both a cost and health perspective for mothers, babies, hospitals, insurance companies and Medicaid. C-sections are more costly than vaginal births and also carry increased risks for both mothers and newborns. Lowering the overall rate of cesarean surgery could mean reduced healthcare costs as well as important gains for maternal and child health.
Though cesarean surgery has become extremely common, it is actually a procedure which entails more risks for both mothers and babies than a vaginal birth. Intraoperative damage to internal organs such as the bowels, bladder, urinary tract and unintentional damage to the uterus or cervix are relatively common, occurring in approximately 12 percent of cesarean sections. Other maternal complications include an increased occurrence of placenta abnormalities in subsequent pregnancies, admission to the intensive care unit, blood transfusion, infection, blood clots, hysterectomy and death, with the chances of these complications increasing with each subsequent cesarean (Dodd and Grivell, 2011).
Kozhimnnil, Law and Virnig (2003) found that even among women who fit the American College of Obstetrician-Gynecologists’ (ACOG) definition for low-risk pregnancy, cesarean rates are still very high and that clinical factors alone could not explain the increase in cesarean surgery. They theorize that rising cesarean rates might be explained by physicians’ practice patterns and hospital policies along with a failure to educate women about the real instead of perceived benefits and risks of cesarean and vaginal delivery.