For years I have believed that once a woman has a cesarean, the choice to deliver vaginally (VBAC) or have another c-section (RCS) for future deliveries should be entirely hers. I've believed that the risks, while different, carry roughly equivalent chances of worst-case outcomes. It is up to each of us to determine which set of risks we are most comfortable with, and go forward making the decision that will allow us to look back without regret. I have struggled to learn to support women who looked at all the evidence and still chose RCS- it is definitely not a choice I would not personally make- but in the end it was never my place to judge someone for making the decisions that she felt were right for her and her baby.
While I still don't feel I have any right to judge women who choose RCS, I have reached a point where I don't feel that is at odds with speaking up for VBAC. I recently read that over 50% of women would like to attempt VBAC, but nationally less than 10% actually do. Why is that? I'm sure there are a certain number of women for whom VBAC is legitimately not an option, but the majority are probably very good candidates and yet they choose (or are forced to choose) RCS. Why?
VBAC is vilified, there's no doubt of that. Lawyers like this Indiana Medical Malpractice Lawyer are all too willing to support the perception that VBAC is in and of itself a needlessly risky procedure that often results in poor outcomes for mothers and babies. There is a pervasive belief among the general public- and among juries- that a c-section represents everything possible being done to ensure a healthy and safe delivery, and I've often seen it said that OB's are never sued for the c-sections they perform, only the ones they don't.
But I don't really want to talk about medical malpractice, I want to talk about why major abdominal surgery is considered the normal way for a baby to be born, just because his mom has a scarred uterus. Recent studies are coming down in favor of VBAC as safer than RCS for moms and babies, and it is absolutely clear that RCS increases future risks for women and their subsequent babies- but even if the risks were equal, why do we believe the intervention is better than the natural process? Why are we burdening our healthcare system with the time and expense of so many cesarean sections when there is an equally safe (possibly safer) and much less invasive alternative?
It is time for this paradigm to shift. I'm not suggesting that the option of repeat cesarean be taken away, but I believe we need to change the starting point when a woman is choosing between VBAC and RCS. In today's obstetric world, RCS is the automatic assumption and women who don't have a compelling reason to attempt VBAC rarely do. It is even more rare for an OB to encourage a woman to choose VBAC. This is completely upside down! We shouldn't have to fight and change doctors and travel for hours to be "allowed" to labor and deliver our babies without being cut open. We should expect to deliver vaginally unless there is a compelling reason to do otherwise, and VBAC should be the first option offered to women with a previous cesarean.
A shift in our thinking, a return to normalzing birth... I'm not idealistic enough to think it would be easy, but I am not cynical enough to think it's impossible either. I still have hope that one day in the future, the 50+% of women who would like to have a VBAC will be supported and encouraged.
Friday, February 19, 2010
Thursday, February 11, 2010
The Gentle Cesarean
For years now I've been a part of the VBAC support forum on BabyCenter, and I've read literally hundreds of women's cesarean birth stories. I've read some positive and empowering stories, and I've read some tragic ones that truly fit the term "birthrape." But I have never read one like the one Joanna Moorhead describes in this UK article titled "Every Bit as Magical." Professor Nick Fisk is pioneering a cesarean technique he calls the "skin-to-skin cesarean," a significant improvement over the clinical and reserved deliveries most c-section moms expect.
Picture this: Instead of being literally strapped to the table with her view obscured by a curtain, the mother is propped up so she can see her baby's birth. Instead of the surgery being performed as quickly as possible, the pace is slower, gentler. Instead of the baby being whisked away, he is immediately placed on his mother's chest. The cesarean is recognized and honored as what it is- this baby's birth- instead of being performed like just another surgery. How wonderful would this be for women who have to have cesareans?
Taking it a step further, how wonderful would it be if all mothers could expect to be treated like their births are amazing, magical, worthy of respect and consideration? No matter how our babies enter the world, birth remains one of the most powerful and unforgettable experiences we will ever have.
Picture this: Instead of being literally strapped to the table with her view obscured by a curtain, the mother is propped up so she can see her baby's birth. Instead of the surgery being performed as quickly as possible, the pace is slower, gentler. Instead of the baby being whisked away, he is immediately placed on his mother's chest. The cesarean is recognized and honored as what it is- this baby's birth- instead of being performed like just another surgery. How wonderful would this be for women who have to have cesareans?
Taking it a step further, how wonderful would it be if all mothers could expect to be treated like their births are amazing, magical, worthy of respect and consideration? No matter how our babies enter the world, birth remains one of the most powerful and unforgettable experiences we will ever have.
Sunday, February 7, 2010
Elective cesarean: The new media darling
In case you missed it, the Today Show televised a cesarean birth. A CBS affiliate in New York is publicizing a "Growing Trend: Expectant Women Schedule C-sections." Obstetric texts are compiled to show the benefits of cesarean delivery, and then those texts are quoted and debated by women who believe cesarean delivery may truly be the best and safest way to deliver babies. Every time I see these glowing portrayals of surgical births, it makes me a little bit sad, more than a little bit frustrated, and even more it makes me angry.
I am angry that we are building a culture perceiving cesarean birth as a low-risk procedure that is safe for babies and not a big deal for mothers. I am angry that women perceive vaginal birth as something to be avoided at all costs, and I am angry at the obstetric community for doing so little to allow women the opportunity to birth in a way that is neither physically nor emotionally traumatic. I am angry because women are making birth decisions based on fear, and I'm angry because the mainstream media buys into and feeds that fear. "Don't worry, honey, you don't have to go through anything terrible to have your baby- watch this video, see how easy the c-section is? The baby is out and safe and they chose the right way to deliver. Next week: brain surgery!" What else can we trivialize?
The reality is that elective cesareans have risks, for moms and for babies. Surgical delivery is not a peaceful, gentle birth any more than vaginal delivery is a hellish squeeze through the maternal pelvis. There are grains of truth in the stereotypes, but there is also a reason birth has evolved as it has. Labor is good for babies, the squeeze through the pelvis designed to clear the lungs of amniotic fluid. There is a reason for birth, and more of us need to speak up about it. Cesarean birth is not the same, it is not safer, it is not risk-free and it is not "no big deal."
I am angry that we are building a culture perceiving cesarean birth as a low-risk procedure that is safe for babies and not a big deal for mothers. I am angry that women perceive vaginal birth as something to be avoided at all costs, and I am angry at the obstetric community for doing so little to allow women the opportunity to birth in a way that is neither physically nor emotionally traumatic. I am angry because women are making birth decisions based on fear, and I'm angry because the mainstream media buys into and feeds that fear. "Don't worry, honey, you don't have to go through anything terrible to have your baby- watch this video, see how easy the c-section is? The baby is out and safe and they chose the right way to deliver. Next week: brain surgery!" What else can we trivialize?
The reality is that elective cesareans have risks, for moms and for babies. Surgical delivery is not a peaceful, gentle birth any more than vaginal delivery is a hellish squeeze through the maternal pelvis. There are grains of truth in the stereotypes, but there is also a reason birth has evolved as it has. Labor is good for babies, the squeeze through the pelvis designed to clear the lungs of amniotic fluid. There is a reason for birth, and more of us need to speak up about it. Cesarean birth is not the same, it is not safer, it is not risk-free and it is not "no big deal."
I can hear the criticism already- this post is unsupportive, I am judging mothers who have to have cesareans, I'm ignoring the fact that cesareans have saved countless women and babies. First, I'm not talking about medically necessary cesareans because clearly there are times that the risk of cesarean delivery is far less than the alternative. My purpose is also not to judge women who have made informed decisions to have elective cesareans. We absolutely need to support women in making informed choices, and that includes women who choose repeat cesareans or even primary elective cesareans. That does not mean I think we should stand silently by while a woman has a primary c-section at 38 weeks for a suspected big baby after being told horror stories about shoulder dystocia by her OB. That does not mean we have to listen quietly while someone says her c-section is better for her baby because her baby won't have to squeeze through the birth canal. That does not mean we should remain silent about the fact that pelvic floor damage is caused more often by pregnancy itself than vaginal delivery- and when it is caused by vaginal delivery it is often associated with highly interventive births, directed pushing, episiotomy. Supporting a woman in making decisions about her birth should be more than simply smiling and nodding and ignoring the stench of the bullshit that is thrown around like fact when it comes to birth.
I think it is entirely possible for women to be fully informed and educated and smart, and still value a different birth experience than I do. I can use myself as a prime example- I 100% believe that natural childbirth (the unmedicated, low-to-no-intervention kind, not just vaginal birth) is the absolute safest way to bring babies into the world. I 100% believe that for low-risk women, intervention is largely unnecessary and often adds needless risk to birth. However, I still chose epidurals with my last 2 VBACs, I still scheduled a medical induction for #3 (didn't make it that far, but I fully intended to induce if I had). After evaluating my options and researching my decisions, the benefits of those procedures outweighed the risks. Anyone else might have done the same research and made a different decision- and I would have fully supported them.
What I do not support, and what I judge, is a woman who deliberately chooses to make an uninformed decision and expects me to sing the praises of her choice. "All that matters is a healthy baby" has become the mantra, yet women are conditioned to believe intervention always equates to better outcomes, and our nation's morbidity and mortality statistics simply do not back that up. We need a big wakeup call, not just "support" that amounts to encouraging ever more uninformed decisions and greater social acceptance of high-intervention deliveries and elective cesareans as the norm. We need the media to stop glorifying elective cesarean and portraying vaginal birth as torturous hell. We need to find a way to have normal birth get the glory that's reserved for surgical delivery today. We need the mainstream media to tell women their options are not limited to either the overmedicalized horror show that passes for birth in many hospitals, or an elective cesearan.
If we don't start demanding change, the trend toward primary elective cesarean will continue. If we don't let media outlets know how unhappy we are with the way they misrepresent the realities of birth, they will continue to support and encourage us to view cesarean birth as the easy, no-muss-no-fuss way to deliver our babies. We deserve better.
Saturday, January 30, 2010
Is VBAC high-risk?
If I've heard it once, I've heard it a thousand times:
"My OB says VBAC is too risky and I should just have another c-section"
"Why would you risk your baby's life just so you can have a birth experience?"
"I'm having a repeat c-section because the most important thing is a healthy baby"
It wasn't that long ago that once you had a c-section, all your babies would be born that way. "Once a c-section, always a c-section" was the rule, and it was arguably a good one since cesareans were performed using a classic, up-and-down incision that extended well into the contracting portion of the uterus. That type of incision has a greater risk of rupturing during subsequent labors than the low-transverse incisions typically used today. With the risk of uterine rupture following a low-transverse c-section right around one-half of one percent, vaginal birth after cesarean (VBAC) has become a real option for women hoping to avoid future cesarean deliveries. And yet, controversy still surrounds the safety of VBAC vs. choosing repeat cesarean (RCS).
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.
Risk assessment is a personal thing and it's not surprising that when we are making decisions about something vitally important- how to get our babies out of our bodies and into the world- even the smallest risks can seem enormous. When we are pregnant the first time, it's just assumed we'll deliver vaginally. Once we have the option of delivering by VBAC or RCS, once we have to choose between risks, once we are forced to decide which set of horrific outcomes we prefer to chance- well, the decision isn't always an easy one. It's made even more complicated when women who want to choose VBAC are told that it's high-risk, or it's implied that they are selfishly pursuing an "experience" at the expense of their babies' health. OBs have endless "requirements" for VBAC moms due to the perception that it is risky- limits on gestation, limits on baby's size, "requiring" epidurals, requiring induction to ensure the hospital is fully staffed, requiring VBAC moms to deliver in the OR rather than an LDR room, continuous monitoring, internal monitoring, no laboring at home... you would think a VBAC mom's uterus is a bomb waiting to explode!! But is VBAC really high-risk?
The first thing I consider is how non-VBAC, vaginally birthing moms are treated. The potential for a complication requiring a truly emergency cesarean is there in any vaginal birth! Cord prolapse and abruption occur in .18% and .4% of labors respectively but those risks are not perceived as great enough to make all laboring mothers "high risk." In a VBAC labor, adding uterine rupture to prolapse and abruption, the risk of needing a truly emergent delivery is raised from about .6% to just under 1%. Does that increase justify a high risk designation?
And what about uterine rupture? Are the consequences of rupture so severe that even a small risk of rupture makes VBAC high-risk? While somewhere between 0.4% and 0.7% of VBAC labors will result in uterine rupture- a complete breach of the uterine wall- it's important to note that even a complete rupture is not always 'catastrophic' in the way that term implies. Less than 10% of complete ruptures result in permanent damage to mother or baby. 1 in 2,000 babies will suffer brain damage or death following u/r in a VBAC attempt. Is that "high risk?" If your answer is yes, would you change your mind if I told you that 1 in 2,500 mothers will die after choosing RCS?
Identifying a rupture when it occurs should be part of the equation, and the only sign that consistently occurs in the majority (but not all) of ruptures is a prolonged period of decelerations in fetal heartrate or bradycardia. This is also a sign of fetal distress in non-VBAC labors, and seems to be identified and responded to well in both hospital and non-hospital birth settings even without use of intervention like continuous monitoring or internal monitoring. Is that high risk?
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?
The additional risk of a cesarean scar follows a woman throughout her reproductive life and adds risk to all her future pregnancies. Uterine rupture is a real risk that is quite dramatically increased with a previous cesarean regardless of how a woman opts to deliver her future children. Women are absolutely entitled to do their own risk assessment and if they desire a more cautious approach to monitoring, both during pregnancy and during labor, they should be able to have that. However, given the increased risk of rupture even prior to labor's onset (which no one worries about), the better outcomes provided by VBAC, and the fact that providers should be ready for an emergent situation even in non-VBAC deliveries and those emergent situations occur with at least the same frequency as u/r, I don't think VBAC in and of itself should be labeled "high-risk."
(For further reading:
http://emedicine.medscape.com/article/275854-overview
http://lib.bioinfo.pl/meid:68748
http://journals.lww.com/greenjournal/Fulltext/2009/06000/Neonatal_Outcomes_After_Elective_Cesarean_Delivery.7.aspx
http://www.truebirth.com/2008/02/new-study-looks-at-multiple-vbac-outcomes/
http://content.nejm.org/cgi/content/abstract/351/25/2581)
"My OB says VBAC is too risky and I should just have another c-section"
"Why would you risk your baby's life just so you can have a birth experience?"
"I'm having a repeat c-section because the most important thing is a healthy baby"
It wasn't that long ago that once you had a c-section, all your babies would be born that way. "Once a c-section, always a c-section" was the rule, and it was arguably a good one since cesareans were performed using a classic, up-and-down incision that extended well into the contracting portion of the uterus. That type of incision has a greater risk of rupturing during subsequent labors than the low-transverse incisions typically used today. With the risk of uterine rupture following a low-transverse c-section right around one-half of one percent, vaginal birth after cesarean (VBAC) has become a real option for women hoping to avoid future cesarean deliveries. And yet, controversy still surrounds the safety of VBAC vs. choosing repeat cesarean (RCS).
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.
Risk assessment is a personal thing and it's not surprising that when we are making decisions about something vitally important- how to get our babies out of our bodies and into the world- even the smallest risks can seem enormous. When we are pregnant the first time, it's just assumed we'll deliver vaginally. Once we have the option of delivering by VBAC or RCS, once we have to choose between risks, once we are forced to decide which set of horrific outcomes we prefer to chance- well, the decision isn't always an easy one. It's made even more complicated when women who want to choose VBAC are told that it's high-risk, or it's implied that they are selfishly pursuing an "experience" at the expense of their babies' health. OBs have endless "requirements" for VBAC moms due to the perception that it is risky- limits on gestation, limits on baby's size, "requiring" epidurals, requiring induction to ensure the hospital is fully staffed, requiring VBAC moms to deliver in the OR rather than an LDR room, continuous monitoring, internal monitoring, no laboring at home... you would think a VBAC mom's uterus is a bomb waiting to explode!! But is VBAC really high-risk?
The first thing I consider is how non-VBAC, vaginally birthing moms are treated. The potential for a complication requiring a truly emergency cesarean is there in any vaginal birth! Cord prolapse and abruption occur in .18% and .4% of labors respectively but those risks are not perceived as great enough to make all laboring mothers "high risk." In a VBAC labor, adding uterine rupture to prolapse and abruption, the risk of needing a truly emergent delivery is raised from about .6% to just under 1%. Does that increase justify a high risk designation?
And what about uterine rupture? Are the consequences of rupture so severe that even a small risk of rupture makes VBAC high-risk? While somewhere between 0.4% and 0.7% of VBAC labors will result in uterine rupture- a complete breach of the uterine wall- it's important to note that even a complete rupture is not always 'catastrophic' in the way that term implies. Less than 10% of complete ruptures result in permanent damage to mother or baby. 1 in 2,000 babies will suffer brain damage or death following u/r in a VBAC attempt. Is that "high risk?" If your answer is yes, would you change your mind if I told you that 1 in 2,500 mothers will die after choosing RCS?
Identifying a rupture when it occurs should be part of the equation, and the only sign that consistently occurs in the majority (but not all) of ruptures is a prolonged period of decelerations in fetal heartrate or bradycardia. This is also a sign of fetal distress in non-VBAC labors, and seems to be identified and responded to well in both hospital and non-hospital birth settings even without use of intervention like continuous monitoring or internal monitoring. Is that high risk?
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?
The additional risk of a cesarean scar follows a woman throughout her reproductive life and adds risk to all her future pregnancies. Uterine rupture is a real risk that is quite dramatically increased with a previous cesarean regardless of how a woman opts to deliver her future children. Women are absolutely entitled to do their own risk assessment and if they desire a more cautious approach to monitoring, both during pregnancy and during labor, they should be able to have that. However, given the increased risk of rupture even prior to labor's onset (which no one worries about), the better outcomes provided by VBAC, and the fact that providers should be ready for an emergent situation even in non-VBAC deliveries and those emergent situations occur with at least the same frequency as u/r, I don't think VBAC in and of itself should be labeled "high-risk."
(For further reading:
http://emedicine.medscape.com/article/275854-overview
http://lib.bioinfo.pl/meid:68748
http://journals.lww.com/greenjournal/Fulltext/2009/06000/Neonatal_Outcomes_After_Elective_Cesarean_Delivery.7.aspx
http://www.truebirth.com/2008/02/new-study-looks-at-multiple-vbac-outcomes/
http://content.nejm.org/cgi/content/abstract/351/25/2581)
Friday, January 22, 2010
7 years later, it still hurts
This morning I read this blog http://omgdgms.com/2009/11/10/chop-shop/ and instantly, I was transported back to my first birth. The induction I "had" to have, the utter lack of informed consent, the complications that I now realize are incredibly common during inductions, the interventions I know I should have refused, the monitoring I should have asked for before agreeing to be induced at all. I hadn't read my birth story in a long time; I much prefer the more positive version I choose to think of to the written version I never finished. Because what happened in reality was not what my birth was supposed to have been- a few lines from my birth story:
Labor! I thought.
and both of them came into the labor room-- this was after I had said I didn't want anyone in the room except my husband and my mom
when I got back to the room we had to start pitocin
I had to be hooked up to monitors all the time
then the downward spiral began
I was stuck in bed, I couldn't do anything for myself
I was tired and scared and frustrated and hurting, and I felt alone
I found myself thinking, "Good lord, could you just keep everybody the fuck out of here???"
she and the nurses kept asking me why I was crying. I couldn't tell them
I asked for the (epidural) consent form and after going to the bathroom one last time I signed it
now I started puking my guts out too. God, it was horrible.
Oh, how I hated it.
We had internal monitors, IV antibiotics, constant checks, catheter... Pretty near every possible intervention. And still, I was no closer to giving birth.
That's where I stopped writing. After I got the epidural I was no longer in pain and I stopped vomiting, but the rest of my labor complications continued. The hours continued to pass and I have to give some credit to my OB- I asked for a c-section long before she agreed it was time to perform one, and Vince was born just before 3 a.m. so I certainly can't say it was a matter of convenience for anyone. But the induction, the labor, were so awful... I felt like I'd been completely abandonded and my wishes didn't matter at all, to anyone. At one point I locked myself in the bathroom, I just wanted to escape it all, have the chance to labor and birth my baby in peace. But I didn't get that chance.
It has been so long since my son was born that I am caught off guard when I realize how emotional I still am about it. I used to feel like a failure but I don't any more. Now I just feel sad, both for the woman I was and for every other woman who has to go through an experience like mine. When did it become okay for birth to be like this? How did we go from twilight sleep and preventative forceps deliveries to this? Is inducing and medicating and offering technology instead of comfort really the answer to a better, safer birth? We've traded one illusion of control for another, and we've convinced ourselves that we are somehow to blame when it fails. The technology is infallable, our bodies are what's broken. We failed to dilate, our babies didn't tolerate labor, we developed infection. It's not because we weren't ready for labor or pitocin-induced contractions are harder on babies or artificial rupture of membranes combined with multiple internal exams increases infection risk. No. Because those things are controllable, we are the wild cards, we are the ones who failed.
Like I said, I no longer feel like a failure. I know I am capable of giving birth, I know my faith in the process was not misplaced. I just wish I could go back in time and sit next to that woman who was me, reach out to her, hold her hand, tell her that she had options. Tell her it is okay to ask questions and even say no. And then, later, I wish I could just put my arms around her, hold her, let her cry out her perceived failures, and tell her that at some point in the future those feelings would fade, and she might even find ways to use her experiences to help other women avoid going through the same thing. I can't go back, though, and my heart aches when I remember how much it hurt to have my first birth be such a testament to the failures of modern obstetrics. It still hurts, even 7 years later.
Labor! I thought.
and both of them came into the labor room-- this was after I had said I didn't want anyone in the room except my husband and my mom
when I got back to the room we had to start pitocin
I had to be hooked up to monitors all the time
then the downward spiral began
I was stuck in bed, I couldn't do anything for myself
I was tired and scared and frustrated and hurting, and I felt alone
I found myself thinking, "Good lord, could you just keep everybody the fuck out of here???"
she and the nurses kept asking me why I was crying. I couldn't tell them
I asked for the (epidural) consent form and after going to the bathroom one last time I signed it
now I started puking my guts out too. God, it was horrible.
Oh, how I hated it.
We had internal monitors, IV antibiotics, constant checks, catheter... Pretty near every possible intervention. And still, I was no closer to giving birth.
That's where I stopped writing. After I got the epidural I was no longer in pain and I stopped vomiting, but the rest of my labor complications continued. The hours continued to pass and I have to give some credit to my OB- I asked for a c-section long before she agreed it was time to perform one, and Vince was born just before 3 a.m. so I certainly can't say it was a matter of convenience for anyone. But the induction, the labor, were so awful... I felt like I'd been completely abandonded and my wishes didn't matter at all, to anyone. At one point I locked myself in the bathroom, I just wanted to escape it all, have the chance to labor and birth my baby in peace. But I didn't get that chance.
It has been so long since my son was born that I am caught off guard when I realize how emotional I still am about it. I used to feel like a failure but I don't any more. Now I just feel sad, both for the woman I was and for every other woman who has to go through an experience like mine. When did it become okay for birth to be like this? How did we go from twilight sleep and preventative forceps deliveries to this? Is inducing and medicating and offering technology instead of comfort really the answer to a better, safer birth? We've traded one illusion of control for another, and we've convinced ourselves that we are somehow to blame when it fails. The technology is infallable, our bodies are what's broken. We failed to dilate, our babies didn't tolerate labor, we developed infection. It's not because we weren't ready for labor or pitocin-induced contractions are harder on babies or artificial rupture of membranes combined with multiple internal exams increases infection risk. No. Because those things are controllable, we are the wild cards, we are the ones who failed.
Like I said, I no longer feel like a failure. I know I am capable of giving birth, I know my faith in the process was not misplaced. I just wish I could go back in time and sit next to that woman who was me, reach out to her, hold her hand, tell her that she had options. Tell her it is okay to ask questions and even say no. And then, later, I wish I could just put my arms around her, hold her, let her cry out her perceived failures, and tell her that at some point in the future those feelings would fade, and she might even find ways to use her experiences to help other women avoid going through the same thing. I can't go back, though, and my heart aches when I remember how much it hurt to have my first birth be such a testament to the failures of modern obstetrics. It still hurts, even 7 years later.
Friday, January 15, 2010
Reducing elective induction reduces cesarean rates
I was discussing a study with my OB during one of my prenatal appointments and he said, "Just because someone says it is so, doesn't mean it is so." I sort of laughed and said "I know" because the obvious counterpoint was that just because he said it was so didn't mean it was so either. At any rate, I ran across this study this morning, and while I can't get to the full text (yet!) I am always happy to find data supporting my belief that induction is associated with cesarean delivery:
http://www.ajog.org/article/S0002-9378(09)00210-5/abstract
A total of 10,166 nulliparas and 9869 multiparas attempted vaginal deliveries. Elective inductions decreased significantly, from 4.3% to 0.8% in nulliparas and from 13% to 9.5% in multiparas. A longer time to delivery was seen for both nulliparas (5.2 hours) and multiparas (4 hours) with elective inductions. Unplanned primary cesarean delivery rates are significantly lower in spontaneously laboring women, compared with those induced. (emphasis mine)
This appears to be so much better than the review I discussed in earlier posts- a large enough study group to be statistically significant, and performed recently, in the US, so it may apply to actual obstetric practice as it exists today.
http://www.ajog.org/article/S0002-9378(09)00210-5/abstract
A total of 10,166 nulliparas and 9869 multiparas attempted vaginal deliveries. Elective inductions decreased significantly, from 4.3% to 0.8% in nulliparas and from 13% to 9.5% in multiparas. A longer time to delivery was seen for both nulliparas (5.2 hours) and multiparas (4 hours) with elective inductions. Unplanned primary cesarean delivery rates are significantly lower in spontaneously laboring women, compared with those induced. (emphasis mine)
This appears to be so much better than the review I discussed in earlier posts- a large enough study group to be statistically significant, and performed recently, in the US, so it may apply to actual obstetric practice as it exists today.
Monday, January 11, 2010
Mainstreaming midwifery
This isn't going to be a typical long blog post, more like a random thought:
Last night I started thinking about how I'd always longed to have my babies either at home or in a local birthcenter that offers midwifery care and waterbirth, but either didn't or couldn't for various reasons. I wholeheartedly believe midwifery should be the standard of care for low-risk women, and homebirth an option for women who desire it. And that got me thinking: what would need to change for midwifery care and homebirth to really become mainstream options in the US? How would it change the face of maternity care? Is it realistic to expect those kinds of changes? And how would the mainstreaming of midwifery change midwifery practice itself? Though I haven't completely thought through this subject yet, I realize the answers are not simple. I'll be exploring this more in future posts!
Last night I started thinking about how I'd always longed to have my babies either at home or in a local birthcenter that offers midwifery care and waterbirth, but either didn't or couldn't for various reasons. I wholeheartedly believe midwifery should be the standard of care for low-risk women, and homebirth an option for women who desire it. And that got me thinking: what would need to change for midwifery care and homebirth to really become mainstream options in the US? How would it change the face of maternity care? Is it realistic to expect those kinds of changes? And how would the mainstreaming of midwifery change midwifery practice itself? Though I haven't completely thought through this subject yet, I realize the answers are not simple. I'll be exploring this more in future posts!
Subscribe to:
Posts (Atom)
