Monday, February 23, 2009

When a Woman's Body Fails Her

Within the past month, I have heard more than a handful of stories where planned vaginal births ended up in "emergency" cesareans, and mom was given a diagnosis of either FTP or CPD. More horrifying, I keep hearing of *ELECTIVE* cesarean surgery, to avoid the pain or possible injury of a vaginal birth, because a woman is led to believe that a VBAC is just too risky, or because she "cannot" find a care provider to support her in one. I continue to be utterly baffled by the mentality in our society, surrounding cesarean sections, ie, major abdominal surgery. The risks are pasted all over the internet, warning women about choosing such a dangerous mode of delivery, and yet...we have the highest cesarean rate that we've ever had as a country. There's absolutely no excuse for a 31.1% ( and that was 2006, we don't know 2007's rates yet! ) cesarean rate. The WHO has recommended a national cesarean rate of NO MORE than 10-15%, which means that roughly 1/2-2/3 of *all* cesareans done are unnecessary!

I'll say it again. Roughly 1/2 - 2/3 of ALL cesareans done right now are unnecessary.

Does that not bother anyone? Ah, but I get the myriad stories of "My body wouldn't dilate", "My baby was too big", "My pelvis was too small", "I have already had a cesarean, and my OB ( SURGEON! ) wouldn't 'do' a VBAC".

I did a recent poll on a mommy-site, to see what reason women were given for their "emergency" c-section. 85% of them said that it was an induction ended in either FTP ( Failure to Progress ), or CPD ( CephaloPelvic Disproportion...pelvis too small, baby too big ). And they believed their diagnosis, because why would their doctor lie to them? They tried *everything*, and their baby just could not come out naturally.

Why is it that women are so ready to believe that their body failed them, rather than the SURGEON that they hired, screwed them over? Maybe not intentionally, no. I'm not saying that all Obstetricians are evil, and I'm also not saying that ONLY Obstetricians are the cause for unnecessary cesareans. Midwives can be just as bad, if not more damaging, IMO. But, let's face it. Women are hiring trained surgeons, but begging to avoid surgery. Why?

Let's go over a VERY common scenario:

First time mom, hires an OB because that's "just what's done". Plans a hospital birth. Really wants a natural birth, or as natural as she can "handle". Excitedly prints up her birth plan, that includes "No cesarean unless absolutely necessary", and has her doctor sign it, who is happy to do so, and says to patient "I ONLY do cesareans when necessary!". Patient gets to her due date. Doctor begins to check her cervix, that is yet "not doing anything". Cervix is high, thick, and closed. Doctor begins planting seeds about induction being necessary if patient is still pregnant by 41 weeks, because her body may need a jump start. And, baby might be a bit bigger since the baby has not dropped.

Mom may not necessarily want to be induced, but trusts that her doctor knows more about childbirth than she does, because she's never given birth before, and he's seen thousands of deliveries.

Does this sound familiar yet?

Patient gets to 41 weeks, cervix is still high, thick, and closed. Baby has not dropped. Doctor fails to inform patient of her Bishop's Score ( chart that can predict the likely success of an induction ), and says to head over to the hospital for an induction the next morning. Doctor also fails to tell patient that the labor hormones are more potent at night ( which is why women usually begin laboring at night ), because it's more convenient to schedule an induction during business hours.

Patient is excited, and nervous, and doesn't do any research, because she believes that she will go in, have baby, and leave hospital happy. She arrives at the hospital between 6 and 7 am, signs paperwork, is monitored, blood drawn, and cervadil is usually administered. For doctors who don't care about the risk of DEATH, cytotec might be administered instead. Patient must lie in bed for roughly an hour, and then is *allowed* to walk the halls if she wishes. But, needs to sport her IV pole and sexy hospital gown as well. Patient is checked a few hours later, and the cervadil has softened the cervix a bit, but hasn't done much dilation wise, so she is informed that the Pitocin is being ordered, and will be started shortly. With the pitocin comes constant monitoring, because of the risk of overstimulation to the uterus, though she isn't told this risk.

Sometimes, the doctor will also suggest breaking the bag of waters, to get things moving more. Patient is not told the risk of causing, or cementing, a malposition along with this procedure, nor of the risk of distress to baby by causing head to hit pelvis unnaturally. ( Meaning before it would have broken on its own ) So now, patient is in bed ( or in a chair if she's *allowed* to be out of bed ), dealing with the unnatural contractions that pitocin brings, and will shortly ask for the epidural that she didn't really want to resort to, just a few weeks ago.

She is given her epidural, and left to lie/sit in bed, while not being able to feel much from the hips down. She is likely not told of the risks ( both short and long term ) of the epidural anesthesia, to both her and baby. However, she signs a blanket consent form, without reading, and happily gets a very long needle inserted into her dural space. She is checked a few more times, and is told that she is making progress, but slowly. So, the doctor is ordering that the unit of pitocin is turned up a bit. Sometimes they will then insert an internal monitor for both contractions, and for the baby's heartrate. The one for baby is a monitor that *screws into the baby's scalp*. Patient is not told of the risk of infection to baby in doing so.

When she is checked again and found at the same dilation as the last two checks, the Obstetrician comes in and talks to her about CephaloPelvic Disproportion, or CPD. He explains to her that her pelvis is not large enough to allow the baby to drop, nevermind be born through it. He tells her how good of a job she has done in labor, and that she gave it her absolute best. He explains that if they continue, there is a risk of injury to the baby, since her pelvis is too small to allow him/her to pass through. He tells the patient and her partner, that he can do a cesarean section, and they can see their baby within 30 minutes. He has a team waiting in the OR.

Or, alternate outcome....patient is finally found to be 10cm, preparations for the birth begin. The bed is broken down, the stirrups are pulled out, and the doctor dons the facemask, surgical gown, gloves, and turns on a very bright light. Mom is told when to push, where and how to push, and for how long. The baby's descent is seen, but baby continues to go back up after mom pushes. After a few of these, the doctor explains that he is going to help mom out, by using a set of forceps, or a vacuum extractor. The "aid" is placed, and doctor pulls on baby, to try and assist in the delivery. After a few tries, the doctor tells the patient that her pelvis is not large enough to allow the baby to pass, and that is why the baby never descended, and that is why the baby was not able to be born, despite the aid of forceps or vacuum. Patient is rushed off to an "emergency" cesarean.


I'm sure anyone reading this has heard a story ( or several! ) that runs along these exact lines. Is it that there are now so MANY women who cannot deliver their own baby, or have screwed up bodies that fail them in the one thing that they were LITERALLY designed for? Or is it that Doctors and Midwives are failing women in not informing them of the risks of the things that they walk into willingly, and equally, the fault of the women for not doing research for the most important thing they will ever do?

It makes me so incredibly sad, and so incredibly angry that women would rather believe that their body is broken, rather than understand that they weren't given a fair shot, and that their choices ( in care provider, place of birth, interventions ) failed them instead. I will agree though that it is MUCH harder to take responsibility. I didn't want to believe that I could have avoided my cesarean, or that I could have avoided my son being in the NICU. That was one of the hardest things that I have ever done. To realize that my choices led to what happened to my body and my son, was heartbreaking.

I don't wish heartbreak on every woman out there who had an obviously unnecessary cesarean, but I do wish that women would become educated. I would rather heartbreak, than elective repeat cesareans. I would rather heartbreak than the belief that a woman's body just didn't work for them, and failed them in becoming a mother.

So above, what went wrong, and why?

* First time moms with a low Bishop Score, is up to 80% more likely to have a cesarean section due to the body not being ready for birth.

* Pitocin is known for causing distress in a baby, as it causes unnaturally strong contractions. If a baby wasn't ready to be born to begin with, the baby was not ready for *any* labor, nevermind unnaturally strong labor.

* Artificially Rupture Of Membranes ( AROM ) is known to sometimes cause a malposition in baby ( if baby is not low in pelvis ), or cement a bad position such as posterior, asynclitic, transverse. It can also cause distress, as the baby's head could have gone from outside the pelvis, to rammed *onto* the pelvis, with no cushion.

* Drugs or Epidural anesthesia are known for slowing or stalling labor progression. The medication also passes through the placenta, and into the baby's blood stream. This can lead to breathing depression, lethargy, problems nursing, and lower apgar scores in baby. Epidural anesthesia can also lead to a spike or drop in blood pressure for mom, fever ( which will be treated as possible infection ), headache ( that can last for weeks ), infection at the injection site ( that can lead to Staph ), nerve damage to the back, and in extreme cases...paralysis.

Epidurals also inhibit the pushing phase. Not only is mom unable to get up into varying positions to facilitate a larger pelvic opening ( lithotomy position causes the pelvis to be up to 20% smaller than in other positions for birth ), has a high risk of instrumental delivery, and perineal injury. Controversially, epidurals increase the risk for cesarean delivery because of these factors. When a woman has an epidural, she cannot efficiently feel when/where/how to push. She loses the ability to push effectively, therefore leading to the risk of higher rates of instrumental delivery.

* Vacuum delivery comes with a list of its own risks to baby. The most common is a hematoma, or a pocket of blood underneath fibrous covering of the skull bone. This can result in a "lump" the size of the vacuum cap. Also common are "superficial" markings to the scalp, or splits in the skin. Less commonly, these can be open to infection. Less common risks include neonatal jaundice, intracranial hemorrhage, and retinal hemorrhage.


But the most damaging risks, in my opinion, are the risks that come with a woman believing that she did everything she could, and that her body just didn't work right. Women anymore have so little belief in their body's ability, and don't look at the risks that come with each of the interventions that are allowed into a normal labor.

My desperate goal is to get women to make more careful choices in care provider, place of birth ( What is your doctor's cesarean rate? What is the hospital's cesarean rate? What is your doctor's track record with NATURAL - not just vaginal - births? What is your doctor's instrumental delivery rate? What's your doctor's episiotomy rate? ) Women need to make truly INFORMED decisions. Not just take the word of their care provider ( whether this be OB, Hospital Midwife, Birth Center Midwife, Home Birth Midwife ), friends, family members, and online pregnancy sites. Women need to understand the possible consequences of their decisions.

So many women believe that inductions are harmless, and therefore don't research the MANY possible risks. Many women believe that epidurals are harmless, and therefore don't research. Many women sign up for repeat cesarean sections, believing that it's safer than a VBAC ( Vaginal Birth After Cesarean ), without actually doing the research.

Women, we're smarter than this. And yet, we allow our instincts to be overridden by a care provider with a medical degree, or a mom who has had more children than we have. We allow our empowerment to be taken away by believing that the hospital is the safest place for ANY birth, and hand over our autonomy as soon as we check in.

I feel helpless so often, because it's constantly pointed out that I have no medical degree. It's true, I don't. But I have devoted the past 4 years to study pregnancy, childbirth, and ALL that goes along with it. Four years to this alone. Every aspect that comes with each. I have attended women in birth who had previously been duped into believing that their body didn't work, and watched as they labored beautifully, and then reached down to welcome their baby into their own hands. The incredible moment where they learned that their body worked just as it was designed to do. When they didn't have any separation from their baby. No nurse taking baby off to the nursery for "observation". No separation, but immediate bonding. Immediate smell, touch, love. Breastfeeding as soon as baby is ready, not when a nurse says it's okay.

I have the honor of attending women in birth, and watching as they unfold in childbirth, and regain their power.

Here is a video of women who were told that their body failed them...and went on to discover that it was their care provider, rather than their body, that failed them.




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Bishop Score and Risk of Cesarean Delivery after Induction of Labor in Nulliparous Women

http://www.ncbi.nlm.nih.gov/pubmed/15802392

Risks of Epidural Anesthesia

http://www.healing-arts.org/mehl-madrona/mmepidural.htm

http://www.breastfeeding.com/helpme/epidural_anesthesia.html

http://www.transitiontoparenthood.com/ttp/foreducators/ceinfo/Side%20Effects%202.htm


Risks of Vacuum - Assisted Deliveries:

http://www.fda.gov/cdrh/fetal598.html

http://childbirth---labour-delivery.suite101.com/article.cfm/the_truth_about_vacuum_deliveries

http://jama.ama-assn.org/cgi/content/full/289/1/46

http://content.nejm.org/cgi/content/extract/341/23/1758

7 comments:

Sheridan said...

Great post. It is so true, how the OBs make it seem like it is the womans fault.
I think a huge problem is that there are not well defined definitions for cesareans.
I came up with some.
http://enjoybirth.wordpress.com/2008/12/29/types-of-cesareans/

TheFeministBreeder said...

Oh, it is all soo, sooo true. And I'm just as angry as you are. What makes me even madder are the situations where a woman tries her ass off to get a vaginal delivery, and her doctor does everything in his/her power to sabatoge that effort.

I got my VBAC after 38 hours of fighting off hospital staff. Looking back I have no idea how I made it through that, except that having another cesarean was just absolutely not an option for me. I would have lost my mind. Now I do everything I can to help other VBACing moms avoid what I went through.

Keep up your good work.
The Feminist Breeder
VBAC birth story: http://thefeministbreeder.typepad.com/the_feminist_breeder/2008/05/jules-michael-birth-story.html

Willow said...

So painfully, horribly familiar... and I see it every single working day. Not to mention having fell victim to it all myself... :(

Birthkeeper said...

FeministBreeder - I'm sorry that you had to fight so hard. That's why I advocate for women making a choice in VBAC'ing where they don't HAVE to fight ( ie, home birth with a supportive midwife ), because labor and childbirth is the LAST place that a woman should have to fight tooth and nail.

I think it's awesome that you fought, and won!!! But, I wish that women would research *all* options, and take the road that will have less obstacles. :)

Birthkeeper said...

My dear Willow...I still don't know how you do it everyday. My heart would be perpetually broken, and my BP would be enormously high.

Love you!

TheFeministBreeder said...

Homebirth after a cesarean is not really an option in my home state of IL. There are only a few midwives who will do it, and they are incredibly hard to book.

Next time I will either travel, or go unassisted if I have to. I will never deliver in a hospital again - that is for sure.

womantowomancbe said...

I've recently found out that the wife of a friend is probably about to have an unnecessarian -- apparently the doctor is pushing a C/s rather than an induction, on or before her due date, because he's pushing "big baby fears" on her already. But this post could be about her -- cervix is not effaced or dilated at all...

I'm frustrated because I gave her several books on birth a few weeks ago. She was planning on having an epidural anyway, but for the doctor to cut her open without even an attempt at an induction...? It just makes me sick. Although an induction is likely to fail (esp. in the backwards hospitals we have around here), so she'd end up cut anyway.