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.

"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?

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.”

Research on the Stillbirth-Cesarean connection

From the Lancet 2003; 362: 1779-84:

Stillbirth linked to cesarean section

Investigating the relationship between previous cesarean delivery and subsequent stillbirth.

Cesarean section can increase the risk of stillbirth in subsequent pregnancies, claim researchers, in findings that add to the growing debate over the acceptability of elective cesareans.

Professor Gordon Smith (University of Cambridge, UK) and colleagues studied data on 120,633 births in Scotland between 1992 and 1998. They found that the proportion of stillbirths was greater in women who had previously delivered by cesarean section (2.4 per 10,000 women) than among women who had only delivered vaginally (1.4 per 10,000 women).

The increased risk of stillbirths with unknown causes began at around week 34 of the pregnancy in women who had undergone a cesarean for a previous birth, regardless of the reason for the procedure.

The association is "biologically plausible," the team comments, reasoning that previous cesarean delivery may influence uterine blood flow and mechanisms of placentation in future pregnancies.

An OB's opinion on C-section

From www.obgyn.net

There are many benefits of vaginal delivery, for both mother and baby. During a vaginal delivery the amniotic fluid is squeezed from the baby's lungs, making it easier for him or her to breathe. This does not happen as much during c-section.

Furthermore, it is a misconception that c-section is always safer for babies than vaginal delivery. Scalpel injuries and trauma to babies during c-section, although rare, can certainly occur. In most cases vaginal deliveries are safer for mothers than c-sections, with some medical studies indicating that the chance of death for a mother is 7 times higher when delivered by c-section versus vaginally.

Contrary to popular belief, a c-section is a major operation, not unlike a hysterectomy in it's complexity and potential complications! These complications may include infection, hemorrhage, scar tissue formation (which may produce lifelong abdominal or pelvic pain), anesthesia complications, opening of the skin incision leading to a very large scar, damage to the bladder or intestines, and the formation of blood clots within blood vessels or the lungs.

These complications are usually much more common with c-sections than vaginal deliveries, although as with all medical issues the patient's individual situation will dictate which complications are more, or less, likely.

An unfortunate side effect of our legal system is that many women are led to believe by malpractice lawyers that a c-section will prevent any and all problems for their baby. This is simply untrue and is a very unsophisticated way of looking at this major operation and pregnancy in general.

D. Ashley Hill, M.D.
Associate Director Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency Orlando, Florida

Cesarean section - the way to go?

More and more women are choosing to go the "cesarean route." After all, most plan to have only one or two babies, and they'd rather put up with recovery after major surgery once or twice than "ruin a perfectly good vagina" as one woman put it.

But does cesarean really preserve a woman's body more than vaginal birth?
Is it really less painful?
Are the risks the same?
If I had all the information on risks and benefits, would I choose a C-section for myself?

A doctor friend of mine whose wife recently gave birth by cesarean to her only child, remarked over dinner the other day (as I was discussing natural birth with someone else), "There's nothing quite like a c-section. Slit it open. Take the baby out. Sew it back up and you're done. No sweating, and moaning, and hours of misery. No natural birth for me. I don't find it compelling!"

Is a c-section really akin to just "unzipping," pulling the baby out and sewing the uterus shut again?

Well, not exactly, according to some nursing students who I was visiting with a couple of weeks ago. They were just finishing their eight weeks of Labor and Delivery in their RN training. One of them was lamenting that she had only seen c-sections, during her clinical days, and never witnessed a vaginal birth in the hospital. (She had seen vaginal births in South America, totally unmedicated, and unassisted by any "professional.")

"So," I said, "What do you think of C-sections? Would it scare you to have one, or does it look better than vaginal birth?"

"Oh, my goodness!" she replied. "If women only got a ten second 'behind the scenes' look at c-sections, they would never opt for one. They look awful! The whole uterus, tugged out of the body, lifted up and set on top of the abdomen for repair. The blood loss... it just looks like you tipped over a cup of water and it's pouring out. And then they stuff a rag inside the uterus and..." she shuddered. "I've helped people with severed limbs and stuff, but a c-section was just really gross."

My friend, Jason, and his wife just had an elective cesarean this week. He called to tell me the baby's weight and all the "proud father" news. I asked him if his wife was into recovery yet.
"Oh, yeah, C-sections don't take long. It only took about 10 minutes and we had a baby!" he exclaimed.
"Except that the c-section looked really awful. She didn't feel a thing. But it took the doctor pulling on the baby's head for all he was worth and three people holding her down on the table to get the little six pound guy out! Afterwards, it all looked... uh, just gross. I tried not to hurl, and couldn't watch the rest of it."

Dr. Deirde Lyell, assistant professor of Maternal-Fetal Medicine at Stanford University in California, has this to say:
"Unless a woman has a compelling reason for needing a C-section, vaginal delivery is still the way to go. A C-section is major abdominal surgery and carries a greater risk of severe bleeding, infection, re-hospitalization and blood clots."

The C-section Epidemic - Jennifer Block

A fabulous op-ed piece, published in the LA Times, written by Jennifer Block, author of "Pushed: The Painful Truth about Childbirth and Modern Maternity Care."

More women are dying in childbirth thanks to the high numbers of doctors and mothers who opt out of normal delivery.

By Jennifer Block
September 24, 2007

Pre-term births are on the rise. Nearly one-third of women have major abdominal surgery to give birth. And compared with other industrialized countries, the United States ranks second-to-last in infant survival. For years, these numbers have suggested something is terribly amiss in delivery wards. Now there is even more compelling evidence that the U.S. maternity care system is failing: For the first time in decades, the number of women dying in childbirth has increased.

The Centers for Disease Control and Prevention last month released 2004 data showing a rate of 13.1 maternal deaths per 100,000 live births. For a country that considers itself a leader in medical technology, this figure should be a wake-up call. In Scandinavian countries, about 3 per 100,000 women die, which is thought to be the irreducible minimum. The U.S. remains far from that. Even more disturbing is the racial disparity: Black women are nearly four times as likely to die during childbirth than white women, with a staggering rate of 34.7 deaths per 100,000.

These high rates aren't a surprise to anyone who's been investigating childbirth deaths. Physician researchers who have conducted local case reviews across the country consistently have found death rates much higher than what the CDC has been reporting. In New York City between 2003 and 2005, researchers found a death rate of 22.9 per 100,000; in Florida between 1999 and 2002, the rate was 17.6. Other reports by CDC epidemiologists have acknowledged that deaths related to childbirth are probably underreported by a factor of two to three.

What's to blame for the poor U.S. showing? True, we are the only industrialized country without universal healthcare. But when it comes to childbirth, we basically have it. Ninety-nine percent of women give birth in a hospital with access to all the bells and whistles -- high-tech machines that continuously monitor the baby's heart rate, drugs that can control the speed of contractions like the volume on a stereo, instruments that can coax a reluctant head out of the birth canal, and surgeons at the ready to perform the mother of all interventions, the caesarean section.

The C-section, now used to deliver 30% of American babies, is such a norm these days that, in some places, doctors and women have taken to calling it "C-birth" or even just "having a 'C.'" Pet names aside, the procedure is major surgery, and although it saves lives when performed as an emergency intervention, it causes more harm than good when overused. Here's why: Caesareans are inherently riskier than normal, vaginal birth. They also lead to repeat caesareans. And repeat caesareans carry even greater risks.

Placenta accreta is one of them. The placenta embeds into the uterine scar from a previous surgery, causing a catastrophic hemorrhage at the time of delivery. Most women with placenta accreta lose their uteri; as many as 1 in 15 bleed to death. In 1970, accretas were so rare that most obstetricians never encountered one in their career. Today, according to a University of Chicago study, the incidence may be as high as 1 in 500 births. And that is all because of caesareans and repeat caesareans.

Obesity plays a part as well because obese women are more likely to have health problems that make a caesarean more likely, and more likely to suffer surgical complications. Still, it all comes back to the "C," which could easily stand for "culprit."

According to a sweeping 2006 study by the World Health Organization, published last year in the medical journal Lancet, a hospital's caesarean rate should not exceed 15%. When it does, women suffer more infections, hemorrhages and deaths, and babies are more likely to be born prematurely or die.

Too many caesareans are literally medical overkill. Yet some U.S. hospitals are now delivering half of all babies surgically. Across the nation, 1 in 4 low-risk first-time mothers will give birth via caesarean, and if they have more children, 95% will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability.

American maternity wards are fast becoming surgical suites. We've become dangerously cavalier about it, but the caesarean rate should be a major public health concern. Universal care alone won't solve the problem; what pregnant women need is entirely different care. They need doctors and hospitals that promote normal labor and delivery. Of course, reducing obesity belongs on the healthcare agenda, and so does curtailing the scalpel.

http://www.latimes.com/news/opinion/la-oe-block24sep24,0,6378847.story?coll=la-opinion-center