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Tuesday, March 17, 2009

The Fight To Give Birth in the Age of Fear-Based Obstetrics

As I quickly approach the 40-week mark in my pregnancy, I am thankful for many things: namely the fact that my body has essentially "proven" itself to not only me but to my OB's. I am preparing for my second VBAC (Vaginal Birth after Cesarean) and while my journey has been fairly uneventful thus far (I won't say totally uneventful, because that's not the truth), it is nothing less than a tooth-and-nail fight for thousands of women to do the same all over the US. 
I am also thankful that my only reason for having a c-section was breech presentation of my first child - not failure to progress, a "small pelvis," or failed induction of labor. I went into labor on my own even then, and had already progressed well despite the fact that we knew the baby had to be delivered via cesarean. With my second pregnancy, to my OB's credit he did offer me the choice to do a VBAC initially (which I declined, knowing nothing about it) and I think he was secretly relieved when I said no. But as I approached 37 weeks, my baby was heads down - something I wasn't even sure my children could do because of a physical defect of my uterus - and realized quickly that I really didn't want to go through the painful recovery of another c-section. 
I consulted with my OB, whom I thought was going to stutter himself into oblivion at my choice. I had since done lots of research, lots of praying, and lots of reading of very positive birth outcomes that I felt was essential to the preparation process. I couldn't believe what I was about to embark on, but with God's help and my husband's support, I could get through this. And I did. Beautifully!
I'm not totally against c-sections: of course I think there are instances where they are totally necessary. Breech presentations, multiple births (although not necessarily with twins alone, as long as they present correctly), severe prematurity, dangerous pre-eclampsia, and fetal distress are all obvious red flags, at least to me. But with a c-section rate of roughly 30 percent in this country, you have to wonder if those reasons are really why women are having c-sections?
More common reasons that the c-section rate is so high is because OB's want to practice "daylight obstetrics" - they want the baby out in time for dinner, essentially. With the ability to control so many facets of our lives, why not birth? Anymore if you go one day past your due date, you seem to be a candidate for induction. Pitocin-happy doctors willingly try and induce (more like coerce) a baby out even if it's not ready. Unfortunately it seems that fewer and fewer women are sent home as a result and are almost definitely candidates for c-section. Pitocin can bring with it a cascade of interventions that can sometimes alter or stop labor completely - increased use of epidurals because of harder, stronger contractions is not uncommon, which can, in turn, stall labor - leading to an increased number of c-sections. 
Insufficient pelvis size is another common reason many women are encouraged to have a c-section. Scores of women are even told their babies are too big to deliver vaginally just by an estimate on ultrasound, which further scares them away from attempting a vaginal delivery. Sadly, there is no definite way to know how big a baby will be until they're born and put on the scales - and ultrasound measurements can be off by as much as a pound either way. Many, many petite women give birth vaginally to "large" babies (according to the March of Dimes, anything between six and nine pounds is considered average) and do just fine. Even many babies deemed to be "stuck" can be birthed vaginally provided the medical practitioner knows to instruct the woman to change positions to facilitate further widening of the pelvis (known as the "Gaskin Maneuver," named for renowned midwife Ina May Gaskin). 
Because of the high rate of c-sections in the US, many women are faced with a two-fold problem: if they want more children, do they deliver them via cesarean too? 
Not necessarily. The mantra "once a c-section, always a c-section" is thankfully being disproved by women everyday in this country, although we still have to fight for the right to do so. But unfortunately few women choose this option - whether because they're uneducated about the risks, their doctors scare them out of it, or they have no interest - which is their right. I would never advocate a woman do a VBAC if she really doesn't want to, but neither should I think women should be scared into repeat c-sections for no reason, either. 
One reason many women are scared away from VBACs is the phrase "uterine rupture." It is possible, but is rare, provided you have a low, transverse incision (bikini incision). Also, your chances of receiving Pitocin to induce labor are less - because it can increase your risk of rupture. To many women, the risks of a c-section, if they even know what they are, are somehow more acceptable than the risks of a VBAC, even though the percentage of complications is about the same. 
Risk of VBAC, with non-induced labor, include:
• uterine rupture - this is rare, and the rate is around 1 percent, depending on which source you site
• risk of needing emergency c-section, should the same complications arise as in the first birth
• if you can't go into labor on your own, induction is not recommended 
Risks of cesarean section include:
• increased blood loss and chance of infection
• respiratory complications in the infant because of spinal anesthesia
• increased risk of scar tissue adhesion, especially after several c-sections (which can cause pain and sometimes infertility)
• premature birth because due dates are off 
• risk of uterine rupture (without even going into labor) (although small, still a risk)
It all boils down to which risks you are more comfortable in taking - because don't kid yourself that a repeat c-section isn't without significant risks, too. Neither of them are decisions that should be taken lightly, but unfortunately many women shrug it off as though it's nothing. This unwittingly affects birth outcomes and choices for thousands of women they don't even know, because they either don't care or aren't willing to fight their doctor for the right to give birth. And if you don't fight it, nothing will change.


Jill said...


I was thinking what a well-written post this was. I see that you are a writer by trade, so that explains a lot. =)