Archives for posts with tag: Caesarean section

There has been renewed interest in cesareans in the news (and on this blog) since the release of the ACOG/SMFM consensus statement on preventing primary cesareans in March.  When all health care providers are following best practices, rates of procedures should be relatively similar in patients with similar risk profiles.  This is not so for cesareans, where rates of the procedure in low risk births (singleton, cephalic fetus at term; woman with no health complications) can range from less than 5% to nearly 60% depending on the hospital.

Recently the Contra Costa Times ran a story about the issue in which they quoted Dr. Kirsten Salmeen (whose research interests indicate that she is interested in shared decision making models).  Here is the section of the story in which she comments on practice variation:

Why such profound variations? Should our standards of medical practice be so flexible?

The answer is “complicated” replies Dr. Kirsten Salmeen of the Maternal Fetal Medicine Division at UC San Francisco. She thinks variations in cesarean rates across the country are “likely due to a combination of factors.” That includes differences in patient populations and preferences, provider availability and coverage, hospital and provider culture, access to anesthesia and surgical obstetric services, and the prevailing medico-legal climate.

For example, Salmeen proposed that a difference in rate might depend upon the scope of available obstetrical services. In a hospital staffed with 24/7 obstetric coverage and resourced to provide a C-section when needed, a woman might be allowed more time for labor with a vaginal delivery. In contrast, that may not be as feasible with a solo or small-group provider who’d have to cancel scheduled clinic appointments with many patients in order to wait upon one patient’s labor.

While resource allocation can affect cesareans, in many countries, scant resources mean that women cannot get cesareans that they do need, which is one reason infant and maternal mortality rates are so high in developing nations where hospitals are not universally accessible by birthing women.  It seems preposterous that a lack of resources would lead to more cesareans–it’s how those resources are allocated.

The more important question in terms of shared decision making and informed consent is what women are told when a doctor performs a cesarean.  Are they given the real reasons as outlined by Dr. Salmeen:

  • Does an obstetrician in solo practice say, “Your labor is normal and you and the baby are doing fine but it looks like your birth is going to take several more hours, and I have patients waiting at the office, so is it okay if I just do a cesarean?”
  • Or perhaps in a state with high malpractice claims, the obstetrician says, “Your labor is normal and you and the baby are doing fine, but you had a brief indeterminate fetal heart rate tracing, and if your baby isn’t perfect, you could use that to sue me, so is it okay if I just do a cesarean?”
  • Or perhaps the obstetrician says, “Our culture here at this hospital is to do cesareans on women who don’t really need them, so let’s schedule yours now.”

Somehow, I think not.  Here is a video, intended to be humorous, in which the “OB” convinces a woman to have a cesarean, which “will be way easier” for him:

 

Unfortunately, the kinds of things the actor says are often not that far from things some obstetricians say in real life.

As Dr. Elliott Main (a generally great guy) points out, a doctor can convince pretty much any woman to have a cesarean.  Few women will refuse when a doctor tells them their baby is in danger.

That’s a much easier sell than needing to get back to the office.

 

The New York Times recently ran an excellent piece on increasing evidence-based medicine in childbirth, Tina Rosenberg’s “In Delivery Rooms, Reducing Births of Convenience.”  One would think that evidence-based practice was not a controversial idea.  But apparently it is–especially in childbirth.

The piece discusses the reasons for hospitals’ varied cesarean rates among low-risk births (healthy women with no prior cesarean and a full term, singleton, vertex fetus).

STV fetus For instance, Los Angeles Community Hospital has a 62.7% rate; up the coast at San Francisco General, the rate is 10.1%.  Remember, these are all low-risk births.

The piece concludes that there are many reasons for the variation, including some not very nice ones, like the convenience of doctors or the fact that most of the fee doctors collect for prenatal care and birth comes from attending the birth (making it worth their while to schedule births for when their partners won’t get the prize). It also discusses various staffing models that may contribute to the rise or fall of cesarean rates.

Then come the comments.

Apparently, some believe that merely presenting evidence about safe and healthy childbirth practices deprives women of choices.  Here’s “Janet”:

My body – my choice. Period.
If in the current medical environment I can elect cosmetic surgery, then I can elect a C-section. No further discussion necessary.
Stop subjugating women by dictating how to deliver.

There are authoritative statements based on supposition or speculation.  “PPippins” had a lot to say in the comments, including this:

Natural birth is not complication free: it harms mothers and babies. Where is the outrage about the babies who die or are damaged during natural births? What of the mothers who suffer unspeakable trauma and damages, require subsequent surgeries, become incontinent? No one ever has anything to say about them.

Of course, all of these things can happen during cesareans, medicated childbirth, operative vaginal deliveries–any birth has risks.  Evidence, however, shows that vaginal birth is safest for women (cesarean more than triples the risk of maternal death), and that two years after birth, there is no statistical difference in incontinence between women who birthed vaginally vs. by cesarean.

There are attacks on people who support natural childbirth.  “Kirsten” is sure there is a conspiracy:

Whoever selected the comments with the green checkmarks was clearly a natural childbirth advocate like the author of the article. It is sort of a religion that they try to indoctrinate you into in many birth education classes. I’m appalled that the NYT is promoting such a poorly supported opinion. A low cesaren rate has nothing to do with the maternal and fetal mortality rates and that is why it is wrong to do what the author did and rate hospitals according to their cesarean rates. Also, the author claimed that the acog supports a 15 percent cesarean rate while linking to a natural childbirth propaganda site. Bait and switch. There is no such acog recommendation.

Actually, ACOG did set a target of a 15% cesarean rate among low risk mothers as part of the Healthy People 2010 goals (the goal was not met).  Cesarean is most certainly tied to maternal mortality and morbidity (and has some elevated risks for infants as well).  While there are definitely those who advocate for natural/physiologic birth, I have never heard any natural childbirth advocate say that women should be forced to have an unmedicated vaginal birth.

Then, there are the anecdotes.  My heart goes out to any woman who loses a child–having a stillborn or infant death is a terrible and traumatic thing.  Certainly there are isolated cases in the U.S. in which a cesarean should have been performed and was not.  This does not mean that all women should have cesareans, just as the fact that some women die as a result of cesarean does not mean that no woman should ever have one.  It’s hard to present facts this way to a woman suffering from such a terrible loss, so we’ll just say it here, and if you want to read the anecdotes, go read the comments on the article.  I’m not going to exploit anyone’s pain.

Finally, there are the arguments that the process of birth doesn’t matter–only the outcome.  And the outcomes we care about set the bar at being alive, and possibly healthy:

The only thing that would tell us about safety is mortality rates (both perinatal and maternal, adjusted for the risk profile of the patient population).
Ms. Rosenberg has sadly fallen into the mind set of the natural childbirth community, which values process (vaginal birth) over outcome (live mother and live baby).
Would you judge a cancer center by how much chemotherapy is “necessary” or “unnecessary” or would you judge it by how many cancer patients survived? Would you judge the treatment of heart disease by how many people got angioplasty vs. how many had surgery, or would you judge it by how many people survived and thrived after hospitalization.
The goal in obstetrics is NOT to maximize vaginal deliveries. The goal is to maximize babies’ lives and brain function and mothers lives.

Of course, as noted in the links above, overuse of cesarean surgery does not contribute to the goal of life, especially for mothers.  Let me respond twofold:

  1. If a hospital has equal or better survival rates by doing fewer heart surgeries or less chemotherapy, I think that’s a great way to assess the quality of care.
  2. By the logic of this comment, as long as you are alive (and maybe physically healthy and not brain damaged), nothing that happens to you can possibly matter.  Were you sexually harassed?  Did you lose your job?  Did your house burn down?  Well, you are alive and healthy, and that’s the only way we can assess your life.  By this logic, no one should ever have a wedding ceremony and reception because you are just as married if you make a quick (and very low cost) trip to the courthouse.  Why does it matter how you got to your married state if you are ultimately married?  Plus, you would be alive whether you had a nice wedding or not, so who cares?

If the commenter doesn’t care about her life experiences, that’s fine.  She can have superfluous cesareans and no wedding and be thrilled with her live state after she loses her job and her house burns down.

But for some of us, the quality of our life experiences does matter.

Plus, at San Francisco General, with its high risk, low income population and 10% term, singleton, vertex cesarean rate, there have been no maternal deaths in the last 5 years, and perinatal mortality is less than half of the national average.

Which just goes to show, having good experiences and being alive are not mutually exclusive.

 

There is an interesting paradox in the arguments of some anti-homebirthers.  They argue both that homebirthing is an elitist practice driven by well-educated, wealthy feminists AND that these women do not know, understand, or have easy access to the “truth” about homebirth (because if they did, they would obviously come to the same conclusion as the anti-homebirthers).

Many of the women driving the rise in homebirth are the most capable of finding information on the risks and benefits of homebirth, and if they make a decision that goes against the anti-homebirthers’ beliefs, they certainly aren’t doing it because of a lack of information on risks.  A simple Google search on “home birth” pulls up many sites; some on the first page include a Wikipedia article that has a research review that indicates a higher rate of perinatal death in American homebirths, a Daily Beast story  called “Homebirth: Increasingly Popular, but Dangerous,” and the website Hurt by Homebirth.  It seems that rather than lacking access to the “truth,” some women simply have different interpretations of the evidence and/or different values than the anti-homebirth crowd.

There is, however, a different crowd of women who plan homebirths—or who have homebirths planned for them—who may or may not have accurate information about the risks of homebirth. If they do, it likely doesn’t matter.  Their choice is constrained by a subordination of their own autonomy to God, or in many cases, their husbands or their church leaders.

Some may have heard of the Quiverfull Movement and the Christian Patriarchy Movement.  The overlap between the two groups is substantial.  Those who are “Quiverfull” believe that they must gratefully accept as many children as God gives them, whenever He chooses to give them.  The Christian Patriarchy Movement believes in, well, patriarchy.  Women must always be under the authority of a man; generally this authority passes from father to husband.  The most well known Quiverfull family is the Duggar family of the TV show “19 Kids and Counting.” Kathryn Joyce has an excellent book on the movements, Quiverfull: Inside the Christian Patriarchy Movement.  Two excellent blogs that discuss the ramifications of Quiverfull and Christian Patriarchy are Love, Joy, Feminism, by Libby Anne, who grew up the oldest of 12 in a Quiverfull family; and No Longer Quivering, by Vickie Garrison, who had seven children before leaving the movement.

Because of the movements’ distrust of secular institutions, some in the movements eschew traditional medical care.  In addition, in part because they start families young and have so many children, many of these families are low income but do not believe in using government programs such as Medicaid.  Of course, many members of the movement go to doctors or licensed midwives anyway, and some even sign up for Medicaid.  But many don’t.  In many cases, it is the husband who makes the final decision about the healthcare of his pregnant wife and the circumstances of her labor and birth.  Sometimes these decisions are in response to the guidance of church leadership.

Amy Chasteen Miller, who conducted a study of unassisted childbirth published in Sociological Inquiry, points out that “women make choices about birth within a web of larger social influences.”  For educated, independent women, these choices may come from a feminist sensibility that leads them to reject a paternalistic and technological model of birth.  For other women, birth choices may be “driven by God.”  In some religious communities,

women see childbirth as fully ‘in God’s hands.’  For these women, seeking medical help for pregnancy and birth reflects a breach of faith and an unwillingness to fully trust ‘God’s will.’

In such circumstances, it is unlikely that women are familiar with the scientific literature regarding risks associated with homebirth, but it is also unlikely that knowing and understanding the risks would have any impact on their decision making–if they had any control over the decision.  Miller writes, “For some women, part of surrendering to God is also deferring to their husbands…”  One woman writes, “I asked [my husband] where we should have the baby.”  Another says, “[My husband] knew we needed to do this baby on our own without a professional birth attendant.”  In these families, Miller notes, husbands “played an active role in monitoring, directing, and evaluating the birth process.”

In her article “My Womb for His Purpose,” Kathryn Joyce tells the story of Carri Chmielewski, a self-described “Homeschooler, Homebirther, Homechurcher,” who had an unassisted childbirth after a complicated pregnancy and suffered an amniotic fluid embolism.  Her baby died.  According to Joyce,

Chmielewski’s husband, who critics charge has erased or hidden much of his wife’s past writing, described her survival as a miracle of God, who spared her even as He took their son.

Melissa, a former Quiverfull daughter who blogs at Permission to Live, was a submissive wife who was active in the web group of Above Rubies, a forum for Quiverfull/Christian Patriarchy mothers.  She says of her prenatal care in the U.S., “I had limited my checkups to only a handful to keep costs down.”  She also got only one of the two recommended shots for her rh-negative blood type and had her children at home.  She could have had comprehensive prenatal care, but her family did not believe in accepting government “welfare” and so went without any insurance at all:

I believed that welfare programs were unnecessary because if every woman just got married to one man and he supported her and her kids there would never be a need for welfare, I believed that Christian rights and privacy were being violated by the government on a regular basis…I remember being on a mommy chat board during my first and second pregnancies and someone started a thread on costs of prenatal care and childbirth. I mentioned that my uninsured home births had cost between six and seven thousand dollars each and felt proud that my costs were so low…
She never mentions anything about her knowledge of homebirth risks, only the “risk” of accepting government assistance.
Anonymous left the following comment at a Recovering Grace post on Quiverfull (ATI is the Advanced Training Institute, a Christian Patriarchy group):
I was an ATI mom for quite a few years and embraced the Quiverfull teachings. After a number of children we had a close call. A home birth and heavy hemorrhaging nearly claimed my life. I was ready to end the child bearing and focus on the children we had, but my husband didn’t agree. Within nine months I was pregnant again. We actually had insurance and I wanted to have the next birth in a hospital, but it was more important to my husband to have a home birth and “prove” his faith. I asked him, “What are you going to do if I bleed to death?” His answer amazed me. “Get a new one.”
This women knew first hand that there were risks to homebirth, ones she did not wish to accept.  Her religion, however, would not allow her to exercise her own autonomy.
According to Birth Junkie, “Born in Zion is a book by Christian ‘childbirth minister’ Carol Balizet, who ‘ministers’ to women during their home births” (I wanted to verify what Birth Junkie writes, but the book is now out of print and is currently selling for $200 per copy, so we’re going to take Birth Junkie’s word for it). She writes of Balizet:

[W]hatever Balizet’s ministry may be, it is certainly not midwifery….her teachings on childbirth are thoroughly unbiblical and even dangerous.  As if all this weren’t bad enough, Balizet believes that to receive any medical care whatsoever is a sin. It is yielding to the “world system” (167) and to the “arm of flesh” (84). Furthermore, taking any drug for any reason is sorcery according to Balizet (171). She refers to people who have never ingested drugs of any kind as “undefiled” and “virgins” (174)….Balizet believes that getting a Caesarean Section is a particularly abominable sin. All women who have had Caesareans have “the same spirit,” the “spirit of Caesar,” who is one and the same with “the Strong Man, the Satanic high prince over the organization and sphere of humanism” because they have “rendered their babies unto Caesar” rather than to God (48). In other words, women with Caesarean scars are idol-worshipers who are demon possessed.

Followers of such a philosophy are likely to be frightened into not seeking appropriate medical care–or bullied into not seeking it by church or family “authorities.”

Vyckie Garrison tells the harrowing story (long but fascinating if you want to read the whole thing) of her belief in her husband’s and God’s authority, and how it impacted her prenatal care and birth.  First she was betrayed by the conventional medical system.  A doctor told her a bone spur made vaginal birth impossible.  When she found out that wasn’t true:

‘Then why have I had three c-sections?’ I wanted to know. Well, it turns out that there really was no good reason–only that the first doctor had run out of patience so declared me to be ‘too small’ to give birth. And because of the first cesarean ~ I had automatically scheduled repeat c-sections for my next two babies.”

Her Christian OB offered severe limitations on VBAC and laughed at her wish for vaginal birth.  Having embraced the Quiverfull lifestyle, she decided to deliver with Judy Jones, an unlicensed midwife and devout Christian.  Because Vyckie had many complications in her pregnancy (for which she did not seek other care), Judy was at their house frequently.  Vyckie writes,

As ‘part of the family,’ Judy was around to witness the way that Warren dealt with the children…She spent a lot of time talking to me about the importance of upholding my husband’s authority…she always backed him up as ‘head of the home’….the wife should pray for the father of her children–but it’s essential that she never contradict him or do anything which might undermine his rightful authority as protector, provider–and priest in the home.

As the pregnancy progressed, Vyckie’s health worsened:

I was feeling particularly horrible…I told Judy that I really needed help–I really needed to go to the doctor. Judy drove to my house and did the usual check and assured me that–although I was still spilling sugar in my urine (+1,000)–I was okay and the baby was fine….Even though we really didn’t have the money for it, I insisted that I needed to go to the OB/GYN. ‘I can’t handle this anymore–I feel like I’m dying!’  I was laying on the couch and Judy got down on her knees beside me and did what she called a ‘diaphragmatic release,’ in which she put one hand under my lower back and her other hand on my lower abdomen and then waited patiently while the uterine muscles relaxed. It did calm me down, and while we waited, Judy told me a bible story…about the time when the children of Israel were wandering in the desert, and the Lord was providing for their every need…[b]ut the Israelites grew…greedy. ‘They had meat in abundance,’ Judy explained, ‘but they suffered leanness of the soul.’  Leanness of the soul … that’s what happens to those who don’t trust the Lord through their trials–those who seek “worldly” remedies and don’t have the faith to believe that God will never give us more than we can handle.

Eventually, after months of complications and a harrowing labor, she had a hospital transfer and an emergency cesarean.  Her recovery was lengthy, and her mother urged her not to have more children.  Vyckie writes,

But what about God? What did He want? His word made it very plain ~ He wanted to bless us and to use our family for His glory. Who was I to say, “No. Sorry, Lord–but it’s just too difficult for me”?

Now that she has left the movement, Vyckie offers the following reflections on her experience:

Because I had made the commitment to welcome every pregnancy as an unmitigated gift from the Lord, and because I also believed that accepting government assistance in the form of Medicaid was tantamount to trusting Caesar to provide for the health and wellbeing of my babies, I desperately sought an alternative to the expensive surgical deliveries.  I know now that it was absurd for a woman with my health issues and high-risk status to eschew all medical care and trust myself and my unborn baby to an unlicensed ‘lay midwife’ – but I was idealistically motivated, and it made perfect sense to me at the time. In fact, I was absolutely certain that it was God Himself who put the idea in my head and lead me to Judy Jones….Judy’s incompetent, negligent, and abusive pre- and post-natal care…seriously endangered my life and my baby’s life, and left me so physically, emotionally, and spiritually traumatized that I suffered severe PTSD for over a year and still sometimes have nightmares almost seventeen years later.

Rebekah Pearl Anast, the daughter of Christian Patriarchy couple Michael and Debi Pearl, married Gabe, a man who quit his job to study the Bible.  The family lived in a rural home outside Gallup, New Mexico, where their electricity has been turned off because they can’t afford to pay the bill.   Rebekah has 6 homebirths assisted only by Gabe.  She does seem to have enjoyed them (at least the first 4):
Now, I have had 4 “unassisted” homebirths. It did save us 20,000 dollars all told, and has been a thrilling and bonding experience for both my husband and I.
However, she has so subsumed her own desires to those of her husband that it is unclear whether she knows how to have her own feelings.  Of her relationship to God, her home, and her husband, she says (DH means Dear Husband),
[I]f your worship of God IN ANY WAY short-changes your husband or son, or makes them feel shut out, then IMO, it is not in spirit and in truth….Remember that your husband is your lord….It really helped me to remind myself ‘this kitchen belongs to DH, the food belongs to DH, the meal is all about DH, and both me and our daughter are helpers for DH…’
Rebekah’s entire life is dictated by the whims and desires of her husband, so whatever knowledge she has of the risks of unassisted childbirth are likely to be irrelevant.
There definitely appears to be a group of women homebirthing under questionable circumstances regarding their knowledge and autonomy–but it isn’t privileged feminists beholden to misinformation campaigns of hippie websites.

The Choosing Wisely campaign was begun in order to reduce unnecessary use of medicine and medical procedures.  Non-medically indicated use is unsafe for patients as well as being expensive.  Not only are there costs involved in the medicine or procedure itself, but there are also costs in treating side effects and other health consequences.

The American College of Obstetricians and Gynecologists (ACOG) has a list they made for the Choosing Wisely campaign, “Five Things Physicians and Patients Should Question.”  The top two items on the list are about elective induction of labor (these two items also made the American Academy of Family Physicians list).  The first warns against scheduling a delivery (cesarean or induction) before 39 weeks unless there is a clear medical indication.  Here is the text of the second:

Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable:  Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

This is similar to the information I provided in my posts on Pitocin and elective inductions.  Before 41 weeks, unless there is a clear medical indication, labor should begin on its own.  Note the caveat that if an elective induction is to occur, the cervix should be “favorable.”  A laywoman might ask what this means.  A favorable cervix is soft, effaced and dilated.  But really the standard that physicians use for determining whether a woman’s body is ready to labor is the Bishop score.

In 1955, Dr. Edward Bishop published a paper (subscription needed to get text) on elective induction of labor in which he looked at the likelihood of induction success based on several factors: fetal position, cervical softness, cervical effacement, cervical dilation, and the “station” of the fetus (how far it was engaged in the woman’s pelvis).  We might question the ethics of inducing labor without medical indication, but Dr. Bishop did find that if the baby was anterior and the cervix was soft,  higher levels of effacement, dilation and engagement made elective inductions likely to work and labors were more likely to be shorter.  This chart from Preparing for Birth sums it up:

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Bishop’s scoring system is still used and has some accuracy at predicting the likelihood of an induction’s success.  Some doctors use a simplified score that just looks at effacement, dilation, and station.

Here are some graphs from Intermountain Healthcare’s care process model on elective induction:

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You can see that higher Bishop scores lead to higher likelihood of a successful induction, and that the higher the score, the shorter the labor.

Nulliparous women (first time mothers) are especially likely to have cesareans when they have lower Bishop scores.  It is important to note, however, that even with a favorable Bishop score, nulliparous women are much more likely to have a cesarean than they would be if labor began on its own, and they are more likely to have operative deliveries (forceps or vacuum).

Dr. Gene Declercq of Boston University and colleagues run a wonderful site call Birth by the Numbers and produced this chart with data from Listening to Mothers III:

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This data does not imply that an induction cannot be successful, that no one should have an epidural, or that a cesarean might not be necessary for reasons having nothing to do with inductions or epidurals.  But the data do give credence to the idea of choosing wisely.  Taking Pitocin to start labor in an uncomplicated pregnancy before 41 weeks is akin to taking high blood pressure medicine when your blood pressure is normal (credit Debra Bingham).  The Bishop score may help to determine if the medicine will not hurt you, but why take it in the first place?  If you do want to go the induction route, however, your Bishop score is a tool to let you know how likely an elective induction is to lead to unnecessary major surgery.

All inductions should be done with full informed consent and should not be scheduled around a care provider’s office hours, vacation time, or child’s birthday party.  The well being of the pregnant woman and her fetus and the woman’s informed choice should be the only considerations.  A woman is a human being and not a vessel to be manipulated for the convenience of others.

It would be hard to find anyone who doesn’t think the cesarean rate is too high.  The World Health Organization says that a 15% rate “is not a target to be achieved but rather a threshold not to be exceeded.”  Healthy People 2020 goals (see section MICH-7) target reductions in primary cesareans and increases in vaginal birth after cesarean (VBAC) as two primary goals in maternity care. In some situations, the benefits of a cesarean far outweigh the risks, but when the surgery is not needed, it has the small but significant potential to cause severe complications for the woman and her baby, and also affects the woman’s subsequent pregnancies.

Cesareans have many advantages for doctors.  The payment for attending a cesarean is equal to or greater than attending a vaginal birth.  While even a fast vaginal birth generally takes at least several hours from the time the woman arrives at the hospital,  performing a cesarean takes about an hour.  Cesareans are not risk-free, but the outcomes are predictable.  And scheduling a cesarean is particularly lucrative and convenient for doctors because they can avoid conflicts with office hours and family/leisure time.

surgery cartoon

Dr. Jonathan Weinstein of Frisco Women’s Health, whose cesarean rate is under 15%, offers the helpful list, Top Ten Signs Your Doctor is Planning to Perform an Unnecessary Cesarean Section on You:

  1. Arrives to L&D immediately after office hours and says, “I just don’t think this baby is going to fit”
  2. Third Trimester, Routine Office Visit, “I think this is going to be a big baby you should just have a C/S” – Did you know? ACOG has very specific guidelines for when it is appropriate to offer a patient an elective C/S for MACROSOMIA (fancy word for large baby). ‘Prophylactic (elective) cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights greater than 5,000 gms (11 pounds) in women without diabetes and greater than 4,500 gms (9.9 pounds) in women with diabetes.
  3. “We should induce at 39 weeks your baby is getting too big” – Did you know? According to ACOG, ‘Induction of labor at least doubles the risk of cesarean delivery without reducing shoulder dystocia (rare situation where baby’s shoulder can get stuck at delivery) or newborn morbidity(complications). Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.’
  4. Performs routine ultrasounds at end of pregnancy to see how big your baby is. Did you know? Ultrasounds at the end of the pregnancy can be 1-2 pounds off. Ask some VBAC patients who were talked into a C/S for this, then had a vaginal delivery of a bigger baby the next time.
  5. “You have a positive herpes titer (or history of herpes); the baby will get it if you deliver vaginally.” Try some Valtrex for the last month of the pregnancy that is pretty much standard of care now. It prevents outbreaks and allows for a normal vaginal delivery.
  6. “Your baby is breech you need to have a C/S” Ever heard of or performed an External Cephalic Version? It really does work.
  7. “You have pushed for 2 hours” (with an epidural that prevents you from feeling anything so you are probably not pushing effectively; this is evident on exam because the baby’s head is still perfectly round, but you do not need to know that) it’s just not going to come out.”
  8. “I scheduled you for an induction at 39 weeks, it is just soooo… much more convenient for you!” (and so much higher risk of ending in a C/S, especially if you are not dilated when you start the induction). At least 80% of my VBAC patients were induced the previous pregnancy. For whose convenience was the induction?
  9. First Visit (7 weeks), “Congratulations you are having twins. I will go ahead and schedule your C/S at 38 weeks, but don’t worry if you go in to labor early I will cut you right away!” Translation, “I am scared out of my mind for you to deliver your babies vaginally because I am not trained on what to do when the second baby is coming, plus it pays more to cut you open. Oh yeah, I don’t have that great a rapport with you because I only spend 2 minutes (fundal height, heart beat and ‘I’ll see you next time’) with you each visit, so I am afraid I will be sued for trying to do the right thing.” (note from Human with Uterus: planned cesarean for twins is not evidence based.)
  10. First Pelvic Exam in Office (7 weeks), “Hmm, your pelvis is pretty narrow”
  11. Bonus Tip: 38-week visit, “Your blood pressure is a little up today you are probably developing preeclampsia or toxemia. That can cause you to have a SEIZURE! The treatment is to deliver the baby. You need a Cesarean Section this is the quickest way to resolve it. Let’s get you up to L&D NOW!” Translation – Preeclampsia or Pregnancy Induced High Blood Pressure is a pain in the butt. If I induce you, it could take 24 hours or more and then I would have to manage your blood pressure, and put you on Magnesium. This is way too inconvenient. Do not worry you can try to have the baby vaginally next time. Yeah right!

For more information on cesarean/induction for “big baby,” see this post from Evidence Based Birth.

Despite reports that cesareans are performed at maternal request, only about 1% of primary cesareans were requested by the woman.  As a woman cannot perform a cesarean on herself, the skyrocketing rate must be driven by providers.  Providers also say that high cesarean rates are driven by liability concerns. A connection between liability environments and cesarean rates exists, but the effects are small.  A natural experiment in Texas, which underwent tort reform, showed that reductions in liability did not lead to corresponding changes in cesarean rates–cesarean rates went up at roughly the same rate as they did in the rest of the country.  Texas cesarean rates are currently 35.3%, higher than the national average.

We might also generally question the ethics of performing a surgery that is in the best interest of the doctor, not the woman and her child.  When a doctor recommends a risky procedure such as major abdominal surgery, women should always ask for references to evidence (meaning documents they can read, not off-the-cuff statistics).  A woman’s care should be a process of shared decision making, not following someone else’s orders.  A woman’s humanity demands nothing less.

unnecesarean

When something goes wrong, we often seek someone to blame.  Sometime the culprit is obvious, as when someone hits you or rams into your car or knocks over your vase.  When things go wrong in a pregnancy, it can be harder to tell what happened.  But having someone to blame is comforting.  Assigning blame allows us to believe that avoiding the blameworthy person’s mistakes will spare us a similarly bad outcome.

Blaming Mothers

People are quick to blame women for any bad pregnancy outcome–miscarriage, preterm birth, still birth, baby with disabilities, baby with genetic disorders, low birthweight baby and on and on and on.  Any choice a pregnant or birthing mother makes, it seems, can be used against her.  A New York Times piece points out that

much of the language surrounding advice to pregnant women as well as warnings is “magical thinking” that suggests that women who do everything right will have healthy babies — and therefore, women who have babies with birth defects failed to do everything right.

Women are blamed for not following a doctor’s orders, even if those orders have no basis in evidence, such as bed rest to prevent preterm birth.

Women may be blamed for not following folk wisdom: some people strongly believe that a pregnant will miscarry if she lifts anything heavier than a frying pan or that her fetus will strangle on its umbilical cord if she raises her arms over her head.

Women may be blamed if they do follow a doctor’s orders if a bad outcome occurs.  Virginia Rutter notes the following case from Paltrow and Flavin’s 2013 article on the criminalization of pregnant women:

A Louisiana woman was charged with murder and spent approximately a year in jail before her counsel was able to show that what was deemed a murder of a fetus or newborn was actually a miscarriage that resulted from medication given to her by a health care provider.

Women may be blamed for choosing a provider or place of birth someone else feels is inadequate.  One mother who planned to birth at home with a registered midwife wrote,

If something does go wrong, with the birth, or otherwise, [my mother] is going to blame me forever, for my “selfishness.” If the baby grows up to have a learning disability or something (for whatever reason), my Mom [who had cesareans] is going to say that it’s all my fault for having a natural birth, that I damaged the baby’s brain.

In fact, blame may be heaped on women for things that others believe have the potential to cause poor pregnancy outcomes, even if the actual outcomes are just fine.  For instance, women are often pilloried for having so much as a sip of wine during pregnancy, even though the evidence of harm in to the human fetus from low to moderate alcohol use is nearly nonexistent.

Women may even be blamed for things that they no longer do, as was the case with Alicia Beltran, who was imprisoned for refusing medical drug treatment while pregnant because she no longer used drugs.

Blaming Providers 

Some OBs openly acknowledge that their colleagues find it difficult to change practice in response to new scientific information–or even old scientific information.  Some examples are recommending bed rest, performing routine episiotomies, and using Pitocin for elective induction of labor.  However, when a woman or her infant develops a complication from one of these routinely prescribed interventions, the physician is rarely blamed for the poor outcome.  In fact, the doctors are often lauded in such circumstances for doing “all they could.”

Doctors  claim that women demand potentially harmful procedures, such as elective inductions or cesareans. Ashley Roman, MD, a maternal fetal medicine specialist at NYU Medical Center said,  “I have definitely seen an increase in C-section requests, even when there is no real medical justification behind it.” But the Listening to Mothers III survey found, “Despite much media and professional attention to ‘maternal request’ cesareans, only 1% of respondents who had a planned initial, or ‘primary,’ cesarean did so with the understanding that there was no medical reason.”

ACOG actually sanctions elective cesareans (albeit reluctantly).  In a 2013 Committee Opinion on elective surgery, ACOG concludes, “Depending on the context, acceding to a request for a surgical option that is not traditionally recommended can be ethical.”  Though their 2013 Committee Opinion on maternal request cesarean says vaginal birth should be recommended, it provides parameters for performing an elective cesarean.

Doctors sometime behave as if they are helpless to say no in the face of maternal request for elective medical procedures, such as cesareans or early inductions.  The director of women’s services at one hospital with a high early induction rate said,

A lot of the problem was the fear among our physicians that if they didn’t do what the patient asked, they’d go find another doctor. It was a financial issue.

Women, however, report that physicians consistently offer elective inductions and cesareans.  On the Evidence Based Birth Facebook page, Megan posted, “I was ‘offered’ an induction at 39 weeks at every visit starting at 34 weeks.”  At The Bump, user Ilovemarfa wrote, “I was induced with my son when I went overdue by over a week and he was estimated to be about 10 lbs 5 oz. My doctor offered me a c section due I possible high birthweight…” Her baby weighed 8lbs 9 oz.  Note that a prophylactic cesarean is only supposed to be considered if the baby is estimated to weigh at least 11 pounds.

Physicians may act as if they are doing women a favor by offering elective procedures.  For instance Emily on Baby Gaga posted,

I’m due [in two weeks]. I went to the doctor today. Last week I wasn’t dilated, but now I am 3 cm. He said if I don’t have the baby by my next appointment, I could pick a day, and they would induce me. No medical reason.

Or the provider may state that the procedure will be done, without any discussion or informed consent process.  On the Evidence Based Birth Facebook page, Becca reported, “[My]care provider did routine 36 week ultrasounds. [I] was told I was going to have a ‘Texas sized baby’ and would be induced if labor didn’t start…before 40wks.”   Dana was told at 29 weeks that “All first time moms need an episiotomy.”

In their Committee Opinion on Maternal Decision making, ACOG recommends,

Pregnant women’s autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman’s broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman’s autonomy.

Despite their acceptance of elective interventions and a professional ethics opinion stating that women’s decisions should be respected, physicians sometimes threaten or persecute women when they refuse interventions–whether they are evidence based or not.  At the blood-pressure-raising website My Ob Said What?, a woman who told her OB that she refused to schedule a routine C section for her twin pregnancy (not evidence based) reported that she was told,

If you do that, then we’ll have to get social services involved and believe me, you don’t want that, Cookie.”

Another said she was told,

If you don’t agree to the cesarean section, we will call Child Protective Services and they will take the baby away for someone to be a real parent.”

A woman in Florida “was ordered to stay in bed at Tallahassee Memorial Hospital and to undergo ‘any and all medical treatments’ her doctor, acting in the interests of the fetus, decided were necessary.”  She was not even allowed to ask for a second opinion (bed rest is not evidence based).

One woman pointed out that doctors are not “reported to social services for child endangerment every time they try to induce a baby who’s not ready to be born, just for their own convenience” but that “if a mother did something for her own convenience that landed her child in the hospital, there sure as hell would be…lots of tough questions, lots of shaming.”

As stated earlier, when bad outcomes happen because of a physician’s choices, people often praise the doctor’s heroic efforts, even if the dangerous situation was caused by the physician.

A prime example is use of Pitocin without medical indication (you can read more about Pitocin here and elective induction here).  Some doctors who want to rush a birth or generate a reason to perform a cesarean practice something called “Pit to distress.”  Nursing Birth has an in-depth explanation with examples, but the short version is as follows:

  • A doctor starts Pitocin to induce labor or augment it (speed it up).
  • The dose is raised until the woman is contracting strongly and regularly.
  • The doctor orders that the dose keep going up, even though the woman’s contractions are already strong (at least 3 in 10 minutes).
  • The uterus becomes “tachysystole,” meaning there are more than 5 contractions in 10 minutes.
  • In many cases, not enough oxygen gets to the fetus under these conditions, the fetus goes into distress, and the mother is rushed to the operating room for an emergency cesarean that “saves” her baby.

Many times, the woman has no idea that the physician ordered that her Pitocin dose be raised, so she doesn’t realize that the doctor caused the fetal distress.  All she knows is that the baby was in distress, and that her doctor saved the baby from a potentially terrible outcome.

Even when bad outcomes occur, lawsuits are not common.  Despite the hype around liability, it doesn’t seem to impact practice the way doctors say it does.  After tort reform passed in Texas, limiting physician liability, the cesarean rate continued to go up at more or less the same rate as the rest of the country.  As one obstetrical nurse said, though physicians and nurses fear lawsuits, “hospital staff are rarely criminally prosecuted for their actions or inactions.”

Blame, Fate and Social Control

Certainly there may be someone to blame when a pregnancy or birth has a bad outcome.  But there may not be.  Blaming a doctor is frightening–it encourages people to question someone they need to trust with their lives–and their babies’ lives.  Fate can be even scarier–no one controls fate.  And in looking someone to blame, it seems society is often more interested in the social control of pregnant women than in rooting out the real culprit.  There may be those who escape unscathed, but nobody wins in this blame game.

I am a big fan of Jill Arnold’s cesareanrates.com, and I encourage you to visit.  Here is Jill’s report on Mississippi cesarean rates.

River Oaks Hospital, which is just outside of Jackson, has the highest cesarean rate in the state of Mississippi:  57.2%.  Just for reference, the national rate is 32.8%,  the average for Mississippi is 38.3%, and the World Heath Organization says that 15% is a “threshold not to be exceeded” because maternal and infant health do not improve when rates rise higher.  To be fair, River Oaks handles many high risk cases from around the state, but the WHO threshold is supposed to cover even high risk populations.  A rate nearly four times the maximum threshold seems excessive.

According to March of Dimes Peristats, the VBAC rate in Hinds County (where River Oaks is located) was 4.3% in 2010, meaning that among women who have already had at least one cesarean, only 4.3% who had another baby in 2010 birthed vaginally.  According to the Jackson chapter of the International Cesarean Awareness Network, River Oaks does “allow” VBAC, though there were fewer than 200 VBACs in the entire state in 2010.

So let’s look at what happens at River Oaks.  The homepage for their Labor and Delivery Center features three links: planning a pregnancy, healthful pregnancy and cesarean.  Hmm….  Here is their list of possible reasons a woman would need a cesarean at their hospital (followed by my commentary):

There are several conditions which may make a cesarean delivery more likely. These include, but are not limited to:

  • Abnormal fetal heart rate. The fetal heart rate during labor is a good sign of how well the fetus is handling the contractions of labor. The heart rate is monitored during labor…If the fetal heart rate shows there may be a problem, immediate action can be taken… A cesarean delivery may be necessary.

We know from my past post on Florida that fetal monitoring is not recommended for a normal labor, and that the evidence suggests that fetal monitoring does not lead to better outcomes for infants but does lead to higher cesarean rates.  In normal labors, the best evidence suggests that the baby’s heart rate be monitored by intermittent oscillation (using a hand-held Doppler at regular intervals).

  • Abnormal position of the fetus during birth. The normal position for the fetus during birth is head-down, facing the mother’s back. However, sometimes a fetus is not in the right position, making delivery more difficult through the birth canal.

It is true that head down facing back is the most common position and that other positions tend to make births more difficult.  However, according to ACOG committee opinion, a skilled practitioner can deliver some breech babies vaginally (a sideways baby who won’t turn has to be delivered by cesarean).  Unfortunately, many practitioners do not have the skills for safe vaginal breech delivery.   A posterior (“sunny side up”) baby can  be delivered vaginally and does not require unique obstetrical skill.  Breech and posterior babies can often be turned, and posterior babies especially often turn themselves late in pregnancy or during labor, making a planned cesarean  unnecessary.

  • Labor that fails to progress or does not progress normally

“Normal labor” has changed.  Many doctors rely on the outdated Friedman’s curve, developed in 1954.  It  does not fit with the  labor progression of contemporary women, who labor under different conditions (e.g. not heavily sedated).  “Active labor” used to be diagnosed at 3 cm of cervical dilation; current thought is a woman should reach 6 cm before being considered in “active labor.” However, many hospitals and many individual physicians still cling to the outdated norms. As women now labor more slowly, this leads to many cesareans for “failure to progress.”

  • Baby is too large to be delivered vaginally

The medical term for a large baby is “macrosomia,”  but the condition is often called simply “big baby,” which always sounds to me like the character in Toy Story 3:

big_baby_17961

Hopefully, most macrosomic babies don’t look like that.  In any case, practice guidelines

do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb)

Yes, you read that right.  ELEVEN POUNDS.  Rebecca Dekker at Evidence Based Birth has some great information on macrosomia.

  • Placental complications (such as placenta previa, in which the placenta blocks the cervix and presents the risk of becoming detached from the uterus too soon). Premature detachment from the fetus is known as abruption.

Placenta previa is a situation in which cesarean is life saving for women and babies.  Please, if you have have placenta previa, follow your doctor’s advice regarding cesarean (but do not go on bed rest).  Abruption may or may not require cesarean, but it is absolutely reasonable that it be considered.  The placenta, however, separates from the uterine wall, not the fetus.  These people scare me.

  • Certain maternal medical conditions (such as diabetes, high blood pressure, or human immunodeficiency virus [HIV] infection)

Sometimes conditions like high blood pressure can mean that the baby needs to be delivered early to preserve the life and health of either the baby or the pregnant woman.  In these cases, an induction can often be tried first.  The choice of induction vs. cesarean for a maternal or fetal medical condition should always be made with the full informed consent of the woman.  I have no idea if that’s the case at River Oaks, but given their cesarean rate, I doubt it.

  • Active herpes lesions in the mother’s vagina or cervix

Yes, if the infection is active, cesarean is a good choice.  The chance of herpes transmission to the infant during vaginal delivery is up to 50%.  However, if the woman has been receiving prenatal care, the herpes infection can be treated in advance, which should allow for vaginal delivery in most cases.

  • Twins or other multiples

I have posted on vaginal birth vs. cesarean for twin delivery.  A new, high-quality study shows that planned cesarean does not improve outcomes for twins as long as Twin A is head down.  In response, the chief of obstetrics as Mass General wrote an opinion piece saying that doctors should plan cesareans for twins anyway.  That appears to be the River Oaks philosophy.

  • Previous cesarean delivery

According to ACOG’s practice bulletin on VBAC, the vast majority of women with one prior cesarean are appropriate candidates for VBAC, as are some women with two prior cesareans.  Probability of successful VBAC ranges from 60-80%.  ACOG says that risks and benefits should be discussed, counseling on VBAC should be documented in the medical record, and the ultimate decision should lie with the woman.  According to the River Oaks website,

A woman may or may not be able to have a vaginal birth with a future pregnancy, called a vaginal birth after cesarean (VBAC). Depending on the type of uterine incision used for the cesarean birth, the scar may not be strong enough to hold together during labor contractions.

Who knows what kind of uterine incisions the docs there are using, because apparently the only way to get a VBAC is to come in pushing and have the baby before they can cut you.

  • There may be other reasons for your doctor to recommend a cesarean delivery.

Perhaps it is 4:30 on Friday.

There is more non-evidence-based care featured on their website, including this video featuring babies who bottlefeed and do not room-in with their mothers (fine if that’s what the woman wants, but not a message that promotes best practices).

River Oaks does not appear to be the place to have a baby if you want a vaginal birth and evidence based care.  But you can go make them some money if you want.

Note: this is my second piece on a hospital with the highest cesarean rate within a state.  You can read the post on Florida here.

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