Weekend Movie: The "Natural" Cesarean

This is a great portrayal of new possibilities. Cesareans can be made gentler, kinder, and more mindful of the humanity of all parties. I've written a before on ways to improve the experience of a cesarean, and am thrilled to see this video getting out there! I especially love the emphasis on keeping the mother and baby together at all times if possible, with skin-to-skin as the foundation. Bravo to this whole hospital team for being open enough to question their own habits and being willing to find a new way.

What did you think of this?

Fire & Rescue

Here's what we're talking about.

You're on the second floor of a burning building. Fire completely blocks the door of the room you're in. Your only chance of surviving is by jumping out the window, despite risk of some injury. Of course you're going to jump. This is absolutely a lifesaving action.

Bruises or a sprain are a probability, a broken bone is quite possible. Other major injuries are a lower risk, but still real. Once in a great while you could even be killed by jumping out the window, but the chances are very low, and it's absolutely worth the odds and the healing time to recover from the fall. After all, staying inside the house means facing certain death. THANK GOD we have the option to jump.

Now take the fire out of the picture. The house is perfectly fine.

Is jumping out the window still an equal choice to going down the stairs and walking out the front door?

It happens almost every time the cesarean epidemic is discussed these days. The most recent skirmish that I know of, which motivated this post, was, relatively speaking, a very minor one (a site rating blogs was discussing our mighty friend The Feminist Breeder). Sometimes the conversations go on for days, comments numbering into the hundreds. No matter the specific conversation, whether it's a story on how significantly the risks increase with multiple c-sections, or the possibility of increased likelihood of various lifelong problems for children born surgically, or simply talking about ways to avoid it, someone - and often multiple someones - posts defensively about their own cesarean experience, pointing out how it saved their life, their baby's life, or the live of a loved one or a loved one's baby. In many cases this is clearly coming from an emotional place, often quite a raw one, and very understandably so.

I would never argue the validity of someone's else's birth, and there is NO doubt that cesareans are lifesaving miracles when they are necessary. No doubt whatsoever. And I believe I can safely say that I speak for the vast majority of birth advocate types on this. I am so thankful that cesareans exist - they truly are a wonder of modern medicine, and we are lucky to live in an age where they are available. Sometimes it gets tiresome to have to preface any discussion of cesareans with this lengthy disclaimer, though, as genuinely as I mean it (and I do really mean it).

Once and for all (maybe): It is the unnecessary ones we are talking about. We know that houses do sometimes catch fire. And we know that sometimes it happens even when the house had been at low risk of catching fire, even when precautions are taken. It is when the house is NOT on fire, and a combination of factors pushes women - and their babies - to jump out the window anyway.

I realize that this analogy is a simplification (as all analogies do eventually break down). A house being on fire is a pretty absolute, concrete situation, whereas the reasons for cesarean are definitely a judgment call much of the time. But there is a core truth there, as well as other ways to stretch the metaphor.

A la: A toaster catching fire CAN, in fact, lead to the house catching on fire, which could then lead to jumping out the window. But does it then follow that as soon as we smell smoking bread, we should jump out the window? I would submit that we try to put out the toaster fire itself first, and further point out ways to avoid the toaster catching on fire in the first place. And we should also give thanks that modern technology has made jumping out the window safer than ever, if the fire department has assembled and is holding a good quality safety net*.

I could go on like this for way too long -but you catch my drift. So once again, when we ("we" being rather broadly defined here) discuss our myriad concerns about the growing cesarean epidemic, we are not denying the truly life-threatening situations that have indeed saved many lives, or criticizing the mothers in those life-threatening situations, or suggesting that she would be a better mother/woman/human if she had refused the lifesaving cesarean. We just don't want other mothers to be pushed out the window for no good reason.


* Thoroughly off-topic aside: one of my best friends was a firefighter and paramedic, working for a time on a campus-based volunteer service. Once year the batch of new trainees was learning how to hold a safety net, and was having some trouble organizing their group to do so effectively. One rookie piped up, "Well, can't we just lay it on the ground?"

S2S as the Standard That Should Be

I wrote a two-parter a while back on cesareans, not (for once) on how to avoid them or about the epidemic in its societal context, but instead about how, if one did become necessary, to make the absolute best of the situation. One post focused on birth plans, and the other on a doula's role when birth becomes surgical. Check them out if you haven't read them - I won't rehash here, but suffice it to say that there is MUCH that can be improved on, for both mother and child.

Needless to say, I was thrilled to see this post by veteran OB Nurse 35 Years, on one of the most potent factors: S2S - Skin to Skin Contact Minutes After C/S in the OR. YES. (And she links to the same excellent breastfeeding video I just shared, hooray!) Skin to skin is vital, whenever an emergency doesn't preclude it, due to so many things, like its positive effect on breastfeeding initiation, regulates temperature, reduces crying, the fact that it functions, itself, as an analgesic for healthy babes, and the simple profundity of, yes, bonding. Check her bad self out:

Why is it so hard for the doctors and nurses to get on board? Most of them understand the word “bonding”. But what many don’t realize is that it took a long time for the actual concept to take hold, to allow “time” for bonding to occur. It sounds silly but many times if the baby and mother are still together after 2 hours…the nurses call that “extended bonding”. I have been doing this for over 35 years now and the changes from the 70′s to now are fascinating and frustrating at the same time. To understand the process of change, we have to sometimes remember where we’ve been.

I wrote about Medical Science vs Natural Childbirth a year ago because I feel history IS important to help us move forward. Often it is about control… but many times nurses and doctors are simply task oriented/ focused and not patient centered. They want to complete all their procedures and charting and move on to the next task. I understand this, there is always a lot to do and document. I work there too! The environment provided to us, the health-care workers, is one in which regulations are abundant and staffing is not always optimal. Flexibility is needed. I know there is a way. This culture just has to change. And it happens in small little doses.

SO–> Skin to Skin immediately after a C/S? I have been told by coworkers, doctors and anesthesia:

“It’s impossible, “

“It can’t be done”

“There’s not enough room”

“This patient (the mom) is in the middle of major surgery!”

“The baby needs to be under the warmer, it’s too cold in the OR.”

Really? Seriously? Watch Me………

And she then goes on to describe various barriers in the OR and how she has learned to cope with them. She closes with a final scenario, with a potent moral to the story:

The baby was crying and pink when born and without thinking about it, the doctor, nurses and myself had him on the baby unit drying him. Mom went panicky! “Give him to me, give him to me! He has to be ON me! You just took him OUT of me, now he HAS TO BE ON ME!” She was literally trying to sit up. Anesthesia was drawing up meds for her (that was his answer). I said “OK here he comes!”. So I didn’t ask anyone’s permission this time….. just held that naked baby in one hand, snapped open her gown with the other and helped him move in. I asked for a warm blanket and looked up to see the other nurse and doctor staring at me. I said “Seriously… she’s exactly right, he does belong ON her!” Anesthesia saw the immediate transformation of his frantic patient to one with calm maternal bliss, admiration and cooing. He was then helpful to let her other hand out. This little boy stayed with mom, breastfed before he was 15 min old and went to the PACU with mom. She was so incredibly happy. I never got to see her after that since it was near the end of my shift and I wasn’t on shift the next few days. I saw that she exclusively breastfed in the hospital and without complication went home on day 3. At least part of her birth experience went according to plan!

If she hadn’t have been so vocal about what she wanted, so adamant… she would not have experienced what she did.

SPEAK UP AMERICA…. MAKE IT HAPPEN

Right on. Keep fighting for this, OB Nurse! We all know cesareans ARE sometimes necessary. There is no question about that - and thank God we have that available to us. But there is no reason that immediate skin to skin contact, and no routine separation of mother and baby, should not be THE standard of practice in all cases except when medically necessary. Make it happen indeed.

ERC: Elective Repeat Cesarean/Early Removal Complications

We wrapped up a great Cesarean Awareness month this April - lots of wonderful birth stories being shared, lots of activism, lots of great media attention to the situation. Just in the past week, I was made aware of an excellent newish blog that you should all run over and check out immediately: Natural Birth for Normal Women. In fact, you could probably skip the rest of this post, as it's primarily dedicated to ganking her content (in the most flattering, props-giving way possible), but if you'd like a Cliffs Notes commentary to some choice selections, read on.

By the way, note her url: useyourvagina.blogspot.com. I prefer it to the official title, actually.

Anyway, Ms. Use Your Vagina does a fabulous job of summarizing the real story with VBAC risks here. This is the kind of post I wish I had written myself, it's just spot-on, and echoes many of the thoughts that spring up for me when reading arguments that overstate concerns about VBAC while glossing over the risks of ERC, and ignoring the risks that that first cesarean introduces to subsequent pregnancies, period. For example:

What is without question is that any pregnancy following a cesarean delivery carries significantly greater risk than a pregnancy in an unscarred uterus. Among those risks are higher incidence of placenta problems including previa, accreta, and abruption; higher risk of unexplained stillbirth; greater risk of preterm labor; and not least, uterine rupture. While we most often associate uterine rupture with a VBAC trial of labor, the reality is that even prior to labor, a woman with a previous cesearean delivery has a risk of rupture twelve times greater than a woman with an unscarred uterus having a normal vaginal delivery. The risk is still incredibly small- about 0.2% prelabor rupture for women choosing RCS, 0.4% rupture in a spontaneous VBAC, somewhat higher for induced or augmented VBACs- but without that scar, the risk is only 0.013%. Whenever we talk about delivery options for pregnancies after cesarean, I think it is important to recognize that we're not comparing VBAC (or RCS) to an uncomplicated vaginal delivery. We're comparing the available options, which are VBAC and RCS, and neither option is risk-free for moms or for babies.

Picture me jumping up and down, nodding my head and pointing at the computer, shouting, "OMG! That! Exactly THAT!" The bolding and italicizing is the author's; the obnoxious red is mine - forgive me, but these are the points that had me shouting "YES!" the loudest.

In that same post (please read the whole thing - I could sing the praises of each paragraph all day, but at some point it'll just get embarrassing for both of us), she brings up something that segues into an interesting thought for me:

What about outcomes? Recent studies are showing that women who choose VBAC have better outcomes overall than women who choose RCS. That's not comparing successful VBACs to RCSs either, it's comparing intended VBACs, whatever the outcome, with scheduled repeat c-section. Less NICU time, less respiratory morbidity, and less time in the hospital. Three times lower rates of infant death in the first month of life. Lower maternal morbidity and mortality. And that doesn't even begin to consider the impact of this birth on future pregnancies, an area where VBAC has clear advantages. High risk?

This time, the bolding is mine. I recently had a real-life situation with a client that reminds me very much of this, and it got my wheels spinning. Without divulging confidential information, a cesarean that was originally scheduled for one date got delayed by almost two weeks due to the doctor's reevaluating her case and deciding a vaginal delivery was the better option. Plans were changed, labor was prepared for . . . and then the opinion was rescinded (again, I cannot delve into the details on why), and the surgery was rescheduled.

Mother and baby were both fine, happily. I was so proud of her for being so open to trying different things, and for being such a great sport. And her baby was just wonderful. As I pondered just how healthy and hearty he was, a thought occurred to me: I wondered if he would have done nearly as well if he were delivered on mom's original surgery date, or if that might have been a bit too early for him? We know so much about how important the last few weeks of pregnancy are. Considering this piece of information, that the outcomes of intended VBACS are better for babies even when it still ends up in a c-section, I have to wonder if much of that can be attributed to the fact that the babies were allowed to cook as long as they needed to, instead of being evicted early.

In my client's case, perhaps on some spiritual, energetic or metaphysical level (you can take or leave this part, of course, depending on your beliefs), the whole topsy-turvy ride that was so unsettling to mom, going back and forth between cesarean and vaginal plans, was baby's way of buying some more time in the womb, to ensure the safest and healthiest arrival possible.

Too airy-fairy for you? I understand. But a vital point remains. Let's say a cesarean truly is warranted, and we know this in advance. OR, mom is very well-informed, and has made this choice for herself (because I will always support that as the fundamental principle, even if I would have chosen differently). Whatever the case, we know it will be a surgical birth. Why does it always, always have to be scheduled, and further, why always so early? I'm genuinely asking. I realize that the purported intent is to prevent mom from going into labor spontaneously. But EXCEPT for cases where even early labor can be risky (I'm thinking of a complete placenta previa, where hemorrhaging is a real concern, and of fetal positioning like a footling breech where cord prolapse could happen with even a small amount of dilation), or other pregnancy risk factors like preeclampisa . . . why?

Really, why? I'm asking in earnest, so any professionals out there with insights, please weigh in. Put me in my place if I'm being outlandish or naive. But hear me out a bit more first:

We've ruled out the riskier situations, so let's say it's just a standard repeat cesarean with no other risk factors. First of all, we know how long labor can last, period, and we know that unless mom has a history of precipitous deliveries, early/latent labor can go on for a looooooong time. I will go out on a limb here and say that even if a uterus is going to rupture - very much against the odds - I very much doubt that it would do so in the mildest early labor.

Secondly, isn't the ENTIRE REASON many promote hospital birth as being the safest (leaving that argument aside for now) because cesareans are so readily available? This point is frequently brought up during discussion of VBAC, the salient zinger being that if a hospital isn't equipped to support VBAC, how in the world can you argue that it's equipped to support any birth at all, if emergency facilities are the bottom line?

So, understanding that there can indeed be individual circumstances that warrant scheduling, and even early scheduling at times, I do not understand why scheduling is always the standard, unless it is purely for convenience. Unless the patient prefers it (after being thoroughly informed of all the pros and cons, it should go without saying), couldn't babies benefit from being allowed to gestate as long as they need to? Couldn't a mom facing a known surgical delivery simply tune in to her body, looking for the earliest signs of labor, and then simply let her doctor(s) know as early as possible and head into the hospital, going in much, much earlier than any mom (VBAC or not) would ever be advised to go in unless they either want to be sent home or hooked up for a very, very long, interventive ride. I think it's worth consideration.

WOW, that was some digression. I still have two other mentions for Ms. Use Your Vagina - I promise I won't pontificate* on either one the way I did the first.

First, she questions the oft-cited belief that induction at 41 weeks and beyond leads to fewer cesareans than spontaneous labor with expectant management. This has never really sat well with me, and here's a snippet to explain why:

[W]hile the authors do conclude that "elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid" the VERY NEXT SENTENCE says "There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided." Hmmmm... What in the world does that mean?

It's something that deserves much further examination, in both of our opinions, but I'm glad she took it on.

Finally, the same author guest posts on Andrea Owen's Live Your Ideal Life site, doing a bang-up job spelling out the real risks of cesareans, period, in a very accessible yet thorough way. She parses through what's listed on the consent form (you know, the part where they go "Oh, this hardly ever happens, don't worry, this is just a formality,") and explains what each one actually means. Bookmark this one, everyone. It's a total keeper.

Ms. Use Your Vagina, a.k.a. Pam C, very pleased to make your acquaintance. I haven't pored over all your archives yet, but look forward to doing so. (I was going to say I'd think of you the next time I used my vagina, but that's not quite right, and miiiiiight give you the wrong idea.)

*If you thought this was long-winded, wait until I post on a few recent writings about breastfeeding and medical professionals . . . Hoo boy.

The Importance of April

April is the cruellest month, breeding

Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.

--T.S. Eliot, The Waste Land

In case you hadn't heard yet, April is officially Cesarean Awareness Month. Why April was chosen, I couldn't tell ya. Perhaps it has something to do with T.S. Eliot (look at the last word of the first line, after all), perhaps it's less poetic and more pragmatic than that. Regardless of reason, there's tons going on, both online and out in the matrix. I won't reinvent the wheel of links that The Feminist Breeder already put together, since she already did a bang-up job. I can tell you about one major local event, for those of you who live in or near Erie, though: our local ICAN chapter is hosting a birth film series over the next two Saturdays!



Saturday, April 10th will feature mother of all birth films, "The Business of Being Born". I cannot imagine that anyone reading this blog hasn't seen this, probably multiple times, but just in case: if you haven't, watch the linked trailer and then hie thee to Netflix or whatever DVD source you use - or come to the film fest if you're around here. Then on April 17th, the less well-known but also excellent "Born In The USA" followed by the brief but uplifting "Birth Day" - NOT to be confused with the interventionpalooza reality show on TLC, but rather a lovely short film about a midwife experiencing her own home water birth. Both events take place at Mercyhurst College's Taylor Little Theater from 1 to 4 pm and will include panel discussions following the films.

Planning the event has been awesome - it came about after the public health department released the 2008 cesarean rates for Pennsylvania, and it was revealed that both hospitals in Erie had rates of 37.6%. GAH. The January ICAN meeting simmered with ideas of how to address it. I was ready to chain myself to the gates of Hamot Hospital with a good old-fashioned picket sign, but eventually, more proactive ideas started to flow. It's shaping up to be a great time - I'm especially looking forward to the panel, which consists of local midwives, doulas, mothers, an OB, and even a high school student. I'm also looking forward to the free baked goods we're bringing to slyly win the masses over to our side.

But as exciting as all that local grassroots action is, what I really wanted to post about today was a minor anecdote from my own life that illustrates just how important something as vague as "awareness" might seem.

A few years ago, I had quite a few conversations with various family members about why I was choosing home birth. They ranged from puzzled but more or less neutral (Mom) to outraged beyond reason (my doctor Dad) to supportive but concerned (my birth mom). The latter conversation was a very good, thought-provoking one conversation. My own mother who raised me never actually gave birth, as I'm adopted, and didn't really seem to have a strong opinion one way or another. My dad, well, that's probably a post in itself, seriously (think Dr. Beetlejuice, only male, and a retired plastic surgeon who nevertheless feels at liberty to pontificate on anything medical, Maude bless him). But my birth mom, with whom I am blessed to have a special relationship, had a unique perspective.

She has given birth FIVE TIMES - mighty impressive, if you ask me. All but one went pretty smoothly (I was especially easy, though she wouldn't have thought so at the time, she says); the one baby who was having a tough time rallied at the end. She expressed a lot of the usual understandable concerns: What if something goes wrong at the last minute? What if you hemorrhage? What if the baby needs resuscitation? I responded to these the best I could, explaining just how well-equipped CPMs are. She said that she did understand that most of the time birth DOES go just fine, but it's the exceptions that you have to worry about, so why not be in the hospital just in case? If you want to give birth naturally, go ahead and do it, just do it in the hospital. Just in case. A perfectly understandable opinion. I described my concerns about being subject to unnecessary interventions in the hospital, interventions that carry risks of their own, and tried to explain the difficulties within the current hospital climate, which has undeniably changed since she last gave birth. Experienced as she is, she hasn't given birth now.

She eventually said herself, without any prompting from me, "Well, I guess there are risks either way, and it's up to you to decide which ones you're comfortable with." Perfectly put. She then said she knew I would make an informed choice that was best for myself, and having expressed her fears, she let them go and never brought them up again. Yet, I still got the sense she wasn't quite all the way there, that there was still a bit of skepticism, perhaps feeling the concern about risks in the hospital was an overreaction. But, being the wonderful, supportive person she is, she remained mum.

Then, just the other day, I was telling her about the ICAN Film Series above, all the planning we were doing, how stoked I am to be a part of it, and we got onto the subject of why we were putting it together in the first place. I told her about the Erie cesarean rates being released, and she stopped dead in her tracks. Yes, I repeated, almost 40% of women in our town apparently are unable to give birth vaginally. She then asked about the national rates, and I told her that the national average was 31.8%.

She was astonished. Somehow, in our conversation two years ago (I can hardly believe it;s been that long), I never mentioned the c-section rates, and she literally had NO IDEA how bad it has gotten over the last two decades. Not a clue. "I know they had gone up, but I had no idea just how much," she exclaimed. And I would think that many women in her generation might think similarly. When she first gave birth to me, the national average was somewhere between 5.5 and 10.4%. (Can you believe that? Wow.) Her next baby, 8 years later, it was 16.5%. A big jump, but still within the realm of reasonable, according to many experts as well as the WHO. By the time she had her last, in 1988, it was up to 24.7%, and clearly becoming a problem, but as she was winding up her childbearing and had never had any really bad experiences in the hospital, it makes sense that it wouldn't really register on her radar.

So, it all became a little clearer. Without intending to make assumptions, she was unintentionally operating on the assumption that the rates were maybe around 15-20%, perhaps a little higher, and that when cesareans happened, hey, they were probably necessary. Why was I making such a big deal?

This is why we need to make a big deal about these numbers, this is why we need to get the news out, this is what spreading Awareness means. WE, the types of people who read birth blogs and pore over the latest articles and enter the breach of comment streams after said articles - we know the statistics, at least the basic ones, and I think we sometimes get so used to ranting amongst ourselves that we forget there's a huge segment of the public that does NOT know out cesarean rate has climbed to one percentage point shy of a full third of all births - they very well may be under the impression that it's still somewhere around 15 percent and wonder why these birth-fixated women seem to be getting all bent out of shape.

There was recently a nice spate of coverage by major media outlets about the all-time highs we're experiencing now, and on the ramifications of these highs. Great, excellent, hit "like" on Facebook and then "share". But we need to keep the pressure on, and use the momentum, and be visible and audible and positive, mixing and stirring. Let's get out there and breed some lilacs.