The Ten Pound Baby - Too Big!

I've heard it a hundred times and I should be used to it. But I'm not.
It happened again last week.

My friend was having her third baby. She's already pushed out two babies without problems - an 8 pound and a 9 pound baby.

She's into natural birth, even considered a home birth... but then got nervous thinking about it and went on with the obstetrician. He is a nice man. I like him a lot. If I had to pick a doctor, he'd be in the top dozen that I know. But he works in the hospital and thinks the way he was trained.

Two months ago my friend came home from a prenatal with the shocking, horrifying news, "Mary, they did an ultrasound and my baby already weighs over five pounds! He's gonna be HUGE by my due date!"

I talked her through it: She'd already pushed out a 9 pound baby. This one probably wouldn't be that much bigger, if even that big. She has a great body for having babies. If she was worried about her baby getting big, she could stay away from refined carbs and sugars.
She looked skeptical. I wondered if she really was scared of doing labor again and was hoping for a c-section. I hoped not, but I had to think that perhaps that was going through her head... I loaned her some books and told her that she'd already done it twice, and I was sure she could do it again.

About two weeks ago, they did another ultrasound. This time she was told that her baby already weighed a whopping TEN pounds! Her doctor didn't like the idea of her birthing a 10+ pound baby, and she really didn't like the idea. They mutually agreed that she'd have an elective cesarean section on the following Monday. She'd be 37 weeks. Everything would be fine.

So last Monday, her belly was sliced open and this "giant baby" was extracted. He weighed 6 pounds, 7 ounces. She sighed and laid there waiting for everyone to put her insides back together while he cried and squirmed in the warmer.

The doctor smiled - another successful c-section! No respiratory problems for the baby, no issues with the mother. The ultrasound estimate of size was a little off... but no harm was done, so that really didn't matter, right?

The nurses smiled, too. All was well as the new daddy stood near his baby and held his hand and the mommy was stitched neatly closed.

This is birth... the American way.

The Trouble With Repeat Cesareans (Time Magazine)

Time Magazine is starting to get it... the mainstream media is publishing articles that are telling the truth about what has gone wrong in our modern maternity care system.


"Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries, proving that 'once a cesarean, always a cesarean'--an axiom thought to be outmoded in the 1990s--is alive and kicking..."

Read the full article here at Time.

Are We Causing Our Incredibly High Preterm Rate?

The San Francisco Chronicle on the national trend towards C-section:

The Centers for Disease Control and Prevention have tracked an increase in preterm births for decades, with the percentage of births delivered before 37 weeks of gestation rising 21 percent between 1990 and 2006. That increase is the main reason the nation's infant mortality rate has stubbornly refused to decline, remaining higher than most other developed nations.

Some preterm births were linked to mothers' smoking, and others to the mothers' lacking insurance. But more than 90 percent of the increase in preterm, nonmultiple births is attributable to an increase in babies being delivered by C-section at 34 to 36 weeks gestation, according to the March of Dimes.

"It comes from a general change in obstetric practice in our society," said Dr. Alan Fleischman, medical director of the March of Dimes Foundation. "The doctors and the women are intervening in a much more aggressive style toward the end of pregnancy."

Fleischman and other medical experts say there are a number of reasons doctors and mothers are choosing C-section delivery - and not all of them stem from medical necessity, the health of the mother or infant.

Read the rest of the article here.

Study: Vaginal Delivery May Increase Maternal Responsiveness to Newborns

Yet another study telling us another good reason why cesarean birth should be avoided when possible.

"We found a significant difference in activity in certain cortical and subcortical areas of the brain in this group of mothers who delivered vaginally compared with those who delivered by cesarean section. Broadly speaking, the cortical brain regions are believed to be important for regulating emotions and empathy," principal investigator James Swain, MD, PhD, FRCPS, told Medscape Psychiatry.

....While the mechanism is not entirely clear, researchers believe vaginal stimulation caused by vaginal delivery results in the release of oxytocin, a neuropeptide that is a key mediator of maternal behavior in animals.

Cesarean section, said Dr. Swain, may alter the neurohormonal experience of childbirth and therefore may decrease the responsiveness of the human maternal brain in the early postpartum.

The investigators are currently looking at 3- to 4-month postpartum data to determine whether these effects of vaginal delivery on the maternal brain endure. Although the final analyses are not complete, Dr. Swain said preliminary analysis in this healthy group indicates the contrast between the 2 groups may not persist, suggesting that mothers who deliver via cesarean section may eventually "catch up" to those who deliver vaginally.

-- Medscape Medical News

Some time I'm gonna compile a list of all the reasons why one should try to avoid a c-section.

As one of my doctor friends says, "We talk about the 'hard' outcomes - the deaths, the morbidity... When do we factor in the 'soft' outcomes - like breastfeeding and bonding and emotional health and on and on?" And then as she often states so simply and yet so meaningfully, "Birth matters. It really does. We better get it right."

"Just don't think about it, Honey, and you'll be okay!"

I recently attended one of my doula client's prenatal visits with her obstetrician.

She had been telling me about her obstetrician for several months. "I like her," she would say. "She seems open-minded and willing to work with me and respect my wishes... but I'm just not sure if she's just stringing me along or not...."

Over all, most of the reports about her doctor sounded pretty good. She did say a couple things about her that concerned me. For one, the doctor couldn't really remember exactly what her c-section rate was, but she assured the patient that it was "pretty low" and definitely not higher than the other obstetricians in the practice because she only does them "when necessary."

I agreed to come along to a routine prenatal visit and meet her doctor. My client wanted me to tell her what my impression of her doc was afterwards.

I was liking her doctor a lot.
She was saying lots of good things, answering questions openly and took plenty of time to discuss anything my client brought up.

And then my client again brought up c-sections. "You know, Dr. Smith," she said earnestly. "I just don't want a c-section with this baby. I'm counting on you to do everything you can to make sure that doesn't happen to me. Surgery just freaks me out and I don't want end up there... I'm trying to get myself educated so that I know about the risks and benefits of various things and can know what is most likely to make a c-section happen. Is there anything I can do to help prevent myself from becoming a c-section statistic?"

Dr. Smith smiled. "Oh, honey! Don't worry yourself about having a c-section! There's only one good way to deal with that fear of becoming a c-section statistic -- Just don't think about it!
You probably won't have one, and if you end up with a c-section, you can just know that it was necessary and you can be happy that you and your baby are healthy!"

Dr. Smith turned back to charting, but my mind was spinning.

Her best advice on avoiding a cesarean section? Just don't think about it!

I wonder how many other docs give this advice to nervous couples expecting their first baby?

Daylight Section

After receiving the email from our mutual friend about her new grand baby's delivery, my friend wrote the following poem, which she has given me permission to share with you...

Daylight section

Your baby is here!

What an awesome blessing!

Congratulations!

Congratulations!

You hear

7 lbs, 3 oz baby girl

Healthy, full head of hair

Your baby is here!

You should be so happy!

Broken water

Ticking time-clock

Fetal monitor, pitocin drop

Doesn’t matter now, be happy!

Rejoice, rejoice, your baby is here!

Happy, healthy, full head of hair.

Tied down, trussed up, starved and drugged

Lied to, terrified, heart tones dropped?

But your baby is here, you should be happy,

Congratulations!

They did their best for you

Congratulations.

Your baby is here.

Prepped for surgery, shaved and scrubbed

Catheters, monitors, gaping wound

Daylight section

Beautiful baby extracted

A good outcome, no distress after all

Congratulations.

…and condolences.

This poem is dedicated to Sofia, Noelle and all the others
who have been cut from their mother’s womb for no good reason

Be Happy! It's a 7lb, 3oz. Baby Girl!

I received this email from a new baby's grandma about week ago. It's the story of millions of American women who don't know whether they should grieve over their surgical birth, or just move on and "be happy" that they have a healthy baby.
After all, what more could they ask for? Their doctor all but promised them a healthy baby.
S/he didn't promise how that baby would arrive, except that it would be in the safest way possible, the best that 21rst century medicine can deliver.

"Noelle" was surgically delivered before noon today

7 lb 3oz.

They say she has a full head of long dark hair and that she is pink and alert when awake, nursing at least every 3 hours.

They sent a picture of her to my cell phone. The picture of Noelle is now my cell wallpaper.

The interventions and subsequent "fetal distress" were horrific. I cried all day long from anxiety over what they did to "Sarah" [daughter in law] and my granddaughter. They tied her, they trussed her, they starved her, they drugged her, they exhausted her and they terrified her.
After that torture, "fetal distress" was inevitable. (Eeek! fetal heart tones dropped to 127!!)
.... It was all conveniently resolved with major abdominal surgery.

In spite of the interventions, Noelle was vigorous upon extraction. Oops, no cord wraps or fetal depression after all, hmmm.... But they got the kid conveniently "delivered" during daylight hours and within the 24 hour deadline from spontaneous rupture of membranes (SROM). Another "good outcome" for their stats.

A good outcome on paper. But was it good for mother and baby?
Did the treatment they received increase their chances of safety, of life, of successful breastfeeding,
of bonding, of happy mothering?

They had a one in three chance of C-section just by choosing hospital birth in the United States.
But 1 to 3 is 100% if you happen to be the ones sectioned.
It's not like my daughter-in-law was only 33% sectioned.

I am grateful that Noelle seems to have weathered the storms of intervention fairly well. But who knows the long term effects? Mommy, on the other hand, is now not only a new mother, but a post operative patient.

There is a place for emergency C-sections. But in this case, the emergency was created by the very system my loved ones blindly trusted to provide "safety".

I was painfully aware of the peril they were entering with their choice of care and helpless to avert the impending tragedy.
I did what I could to provide accurate information and techniques for dealing with a system that is more about avoiding medical liability than supporting the normal process of birth. (And I had prayed that they would "luck out" and end up being blissfully ignorant of the dangers they had avoided.)

I am so angry at the successful "sale" of "services" with which my loved ones got a total "bait and switch".

The reality of grandmotherhood has not really set in. I SO want to be happy.
And I am grateful for the precious child.
But I am heartbroken by the inhumane way she and her mother were treated at such a crucial time in their lives.

Thankfully, Sarah planned to breastfeed which seems to be going fine.

It's tomorrow now. Maybe I have cried myself out and I can get some sleep now.

Is It Safer to Have Another Cesarean or Attempt a Vaginal Birth (VBAC)?

And the evidence in favor of vaginal birth over repeated cesareans just keeps piling up!
Check out this most recent study, just published in the journal of
Obstetrics & Gynecology
(2008;111:285- 291).

The study's OBJECTIVE:
To estimate the success rates and risks of anattempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs.

METHODS:

From a prospective multicenter registry collected at 19 clinical
centers from 1999 to 2002, we selected women with one or more prior low
transverse cesarean deliveries who attempted a VBAC in the current
pregnancy. Outcomes were compared according to the number of prior VBAC
attempts subsequent to the last cesarean delivery.

RESULTS:

Among 13,532 women meeting eligibility criteria, VBAC success
increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%,
and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively
(P<.001).

The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52%(P=.03) .

The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.

CONCLUSION:

Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy. Contrast that study with another from Obstetrics & Gynecology (2006;107:1226- 1232) which found that there is maternal morbidity associated with multiple repeat cesareans.

OBJECTIVE:

To estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries.

METHODS:

Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay *significantly increased *with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.

CONCLUSION:

Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

A Clearly Defined Risk of Cesarean Birth: Hysterectomy

The American College of Obstetricians and Gynecologists’ “Green Journal” contains some enlightening news in the January 2008 issue that every pregnant woman should know. It’s contained in a report about a very recent study titled, “Cesarean Delivery and Peripartum Hysterectomy” -- Obstetrics & Gynecology, Knight et al, 2008; 111:97-105-

Check it out here: http://www.greenjournal.org/cgi/content/abstract/111/1/97

I hope you have a friend with access to the medical journal who can get you a copy of the complete study. It’s a great resource to keep on hand… and to give to anyone who has been told that “cesarean is about equally safe when compared to vaginal birth”!

The study was a population-based, matched case-control study that studied 318 women who underwent peripartum (around the time of birth) hysterectomy between February 2005 and February 2006 and 614 matched control women. The study was done in the United Kingdom, using the United Kingdom Obstetric Surveillance System.

The conclusion of the study was:

Peripartum hysterectomy is strongly associated with previous cesarean delivery, and the risk rises with increasing number of previous cesarean deliveries, maternal age over 35 years, and parity (number of pregnancies carried to over 28 weeks) greater than 3.

Here are a few of the most interesting and relevant findings of the study:

Women who were having their first cesarean delivery were approximately 7.13 times more likely to end up with a hysterectomy (as compared to an equal control group having a vaginal delivery instead) by the time it was all over.

By the time it was the woman’s second or more cesarean delivery, her risk of hysterectomy was over 18 times greater than the woman having a vaginal birth!

~Women undergoing their first vaginal delivery were found to have a
1 in 30,000 chance of having a peripartum hysterectomy

~Women undergoing their first cesarean delivery were found to have a
1,700 chance of having a peripartum hysterectomy.

~Women undergoing their second cesarean delivery were found to have a
1 in 1,300 chance of having a peripartum hysterectomy

~Women undergoing their third or more cesarean delivery were found to have a
1 in 220 chance of peripartum hysterectomy.

ACOG’s journal said it themselves:

“This study has confirmed the significant risk of peripartum hysterectomy associated with prior cesarean delivery. These data provide evidence that cesarean delivery leads to a greater than seven times increase in the odds of having a peripartum hysterectomy to control hemorrhage. A similar risks was noted in a recent U.S. study using the Nationwide Inpatient Sample. We have also been able to identify that the risk also then extends beyond the initial cesarean delivery into subsequent deliveries; women who have more than one previous cesarean delivery have more than double the risk of peripartum hysterectomy in the next pregnancy, and women who have had two or more previous cesarean deliveries have more than eighteen times the risk. This full quantification of these risks provides the evidence needed to comprehensively counsel women about the risks of primary cesarean delivery and to counsel against cesarean delivery without a specific medical indication.”

The article winds up with a statement:

“Although fortunately a rare condition, peripartum hysterectomy nevertheless represents a catastrophic (and sometimes fatal) end to a pregnancy for any woman, regardless of whether she considers her family to be complete.”

Kudos to your obstetrician if s/he brings up this info when informing you of the risk of Cesarean section birth!

Frank Conversations on Cesareans

Most of the “risk” that we hear discussed for Cesarean section includes the possibility of

~post-operative infection,

~blood clots,

~anesthesia complications,

~damage to the bladder and bowels,

~potential problems with future pregnancies like infertility, miscarriage, placenta accreta

and placenta praevia

~and in some rare cases, even death.

Yet, few obstetricians really cover these potential complications in a way that will give a birthing mother a realistic view of what all her C-section could entail – a whole lot more than her idea of “I’ll be kind of sore for a few days or weeks.”

A friend of mine who recently had an elective cesarean developed blood clots afterwards and was shocked to hear that they could have been a result of how she chose to have her baby. Of course, she could have read up on the potential complications and figured that out herself ahead of time, but really, physicians should either thoroughly inform their patients themselves or see to it that they are reading books and doing research and getting informed during their pregnancies. And more than just reading, “What To Expect When You’re Expecting” or watching birth stories on TV.

Sure, of course, the anesthesiologist comes in and rattles off the usual, “you could die, be permanently paralyzed, etc.” stuff as the laboring mother is doing her best to hold herself together and prepare for the long ride down the hall to the OR, wondering if her baby will be okay. Of course, she nods and says she understands and scribbles her name on the paper in between contractions. But does she really understand what she’s signing up for?

That’s what I wonder. What kind of conversations do doctors have with their pregnant patients about the possibilities of a cesarean? …Not only that it could happen to them for various reasons (some good and some not so good), but that by simply having a cesarean, they are increasing their risk for many more complications.

Do they have frank conversations with their patients about weighing risks and benefits of a cesarean for a non-life threatening issue that comes up in labor (i.e. labor isn’t happening as fast as usual) if they are planning to have more children in the future? Or do they just imply that, “If you end up with a cesarean, trust me, it will be for a good reason to make sure you have a live, healthy baby. Vaginal births are great, but don’t get your hopes too high. You don’t want to be disappointed if it doesn’t work, because, really, your goal is a healthy baby, not how you have your baby.”

What Are the Risks of Cesarean Section?

What are the risks of having a Cesarean section? …The risk of having two, even three C-sections? …For the mother, for the baby?

What are the risks of vaginal birth? …For the mother, for the baby?

If you are the typical American woman wondering about these questions, you’ll probably ask your doctor, perhaps check out a few resources online and see what the most popular pregnancy guide book, What to Expect When You’re Expecting has to say. You might even ask your childbirth educator about c-sections, and she would probably help you feel more prepared for it, by explaining when it is likely to happen and how you may feel about it if/when it happens to you.

Hearing women talk about cesareans has often made me wonder exactly what the average pregnant woman does and doesn’t know about having a c-section when she walks into the hospital to give birth. I’m on a mission to find out…

Is she adequately informed of the risks? Does she have a clear idea of the risks and benefits? Does she know as much about this procedure on her and her baby’s body as she does about purchasing her new car and comparing models?

I checked out What to Expect When You’re Expecting, and no where in its 437 pages could I find even one paragraph informing mothers of the potential risks for themselves when undergoing Cesarean delivery. The most I found for mothers was information on what a C-section would be like and how to be calm as you were wheeled back to the operating room for an emergency c-section, and then what recovery would entail – pain around the incision, possibly nausea and vomiting, possibly referred shoulder pain for a few hours and possible constipation, then it should be 4-6 weeks before you feel completely back to normal.

And this quote to put everyone’s fears to rest –

Question: “My doctor told me I will have to have a cesarean. But I’m afraid the surgery will be dangerous.”

Answer: “Today…cesareans are nearly as safe as vaginal deliveries for the mother, and in difficult deliveries or when there’s fetal distress, they are often the safest mode of delivery for the baby. Even though its technically called major surgery, a cesarean carries relatively minor risks – much closer to those of a tonsillectomy than of a gall bladder operation, for instance.”

Hmmmm…I’ve heard a few other things about cesareans recently. I’ll post them here as I get a chance…