Thursday, July 29, 2010

Are all cesareans necessary?

In a blog titled "The Myth of The Unnecessary Cesarean" Dr. Nicholoas Fogelson argues that while many cesareans may be preventable, it is impossible to truly call any specific c-section "unnecessary" because we don't know what would have happened had the surgery not been performed. There's some excellent discussion in the comments (and I can't tell you how great it was to see the doctor coming back and responding!), I posted the topic for discussion on BabyCenter's VBAC board, and the discussion has continued on other blogs as well. As you might imagine, many who feel strongly about the cesarean epidemic are taking Dr. Fogelson to task, saying he's missing the point and sometimes suggesting he is no different from any other scalpel-happy OB.

I beg to differ.

Don't get me wrong. I understand the necessity of questioning the reasons behind an unwanted cesarean. I understand needing to look back and find failure in the system that put you in the OR rather than finding failure in your body. I spent literally years trying to pin down how I really felt about my own c-section, and after almost 8 years I still have not been able to finish writing my birth story because by the time I've read what I do have written I'm an emotional wreck and just can't face it. And yet... when I read the responses to Dr. Fogelson's article, what strikes me is the defensiveness, the aggressiveness, the instinct to attack over a single turn of phrase rather than consider that perhaps we are trying to acheive the same goal with different words.

Words are powerful, and the way we talk about birth is important. I've been taken to task for using the word "normal" in my blog title, we talk about how discouraging it can be when we're told we'll be "allowed" to have a "trial" of labor, and I've even seen heated debates about whether or not a cesarean should rightly be called a birth at all. While the perspective offered by this OB may raise our hackles, I think it can be helpful if we sometimes lower our defenses and agree to speak the same language when we're talking about birthing options and outcomes.


  1. Of the friends of mine that have had c-sections, none of them were "allowed" a trial of labor. ALL of them were talked into "elective c-sections" weeks before their babies due date. None of the doctors were willing to consider that it was safer to wait until due dates before considering scheduled c-sections. None of the moms that have had c-sections thought that it was imperative to save their baby's life in hindsight, but were made to feel that if they continued pregnancy, their babies would be at risk.

    My step mother and my best friend were both talked into elective c-sections at 28 weeks. Although both were high risk, one had diabetes and the other had "poly cystic
    ovarian syndrome". My step mother was told her baby would be too big to birth if she continued her pregnancy and allowed the 28 week old fetus to be born via c-section. At birth, my half brother was 3 lbs 8 oz. Hardly a big baby. He spent 4 weeks in NICU and spent of the first year of his life in and out of surgeries that every peds surgeon told my step mother would not have been necessary if they baby had been permitted to stay in utero longer.

    My best friend was told that her due date could not be trusted and they believed she was already at term (based on mother's weight gain, not any other factor) and her daughter was born 4 lbs 2 oz. Again, obviously not a full term baby.

    I know these are just two anecdotal stories, but I am sure that both of these cases were unnecessary c-sections. These forced births also inflate prematurity stats. I really think that if allowed to progress on their own, both babies and mothers would have been better off waiting. Neither mother feels that the OBs made good decisions regarding their care. They both feel guilt over allowing a doctor to convince them to have serious surgery under the guise of saving babies lives.

    True, there is not way to know what would have happened if the pregnancies had lasted longer. Still, I am pretty positive that at the very least, both infants would have had more weight and stronger bodies. Its sad to see little babies being brought into the world with so many odds stacked against them when if doctors employed a little more patience, perhaps they could have avoided more unnecessary surgery, not just the initial c-section.

  2. I'm so sorry for your friend and stepmother. :-( If an OB pushed a *28 week* cesarean on me under the guise of the baby being too big to deliver vaginally, I'd have his ass in court for malpractice. I honestly can't imagine a situation where a doctor would deliver a baby 3 months early, unless the mother's life was in extreme danger. Did you mean to say 38 weeks? I would agree that scheduling at 38 weeks is still too early, and I personally know women whose babies spent time in NICU after 38-week c-sections, but I suppose it is at least somewhat defensible since it meets the definition of "full-term."

    I also completely agree that it's sad when women are forced or coerced into c-sections they neither want nor need. What I could gather from the comments led me to believe this particular doc wouldn't find it acceptable for a mother to be misled or lied to either, and he does call for greater access to VBAC.

    Still, when I first read this article and the responses to it, I just wanted to jump in and ask women to LISTEN, not just to this OBs disdain for the term "unnecesarean" (a word I personally LOVE because it is simple, elegant, and pointed), but to the rest of what he was saying. When he talks about the Friedman curve being crap, when he says there are too many c-sections, when he agrees that the criteria for an "indicated" cesarean should be discussed and debated and perhaps changed-- Those are all things that sound rational and reasonable, and yet the activists (including my internal activist) yell and scream because we are being asked to reconsider our use of one word. Is it really a sign that this OB doesn't get it? Or is it a sign that *we* don't get it either, and just like we accuse OBs of not caring about our perspective, we're refusing to care that they have a valid perspective different from our own?

  3. Definitely 28 weeks. Barely over half way. I know anecdotal evidence isn't science, but it does affect my opinions.

  4. The friend with poly cystic... they estimated the baby's age as 28 weeks after she was born. They based this gestational age on the babies size, skin transparency, and head circumference. My step mother did no her conception date, so her baby's gestational age was accurate.