fetal morbidity

Mamas on Bedrest: Cesarean Awareness Month

April 25th, 2012

April is Cesarean Awareness Month.

I have really mixed feelings about cesarean sections. Having had 2 cesarean deliveries and knowing that at least in the case of my first one, it pretty much saved my life and the life of my daughter, I can’t be entirely “anti-cesarean section”. But in the United States thousands of women have cesarean sections for bogus reasons and that is what this movement and month of awareness is really all about.

So what are the facts about cesarean sections?

  • Cesarean deliveries are one of the most commonly performed surgeries in all of medicine. The other most commonly performed surgery is a hysterectomy.
  • Cesarean deliveries currently account for some 32% of all deliveries in the United States annually.
  • Originally, Cesarean deliveries were intended to birth a fetus when the mother was dead or dying. It has since evolved to be indicated for “large babies”, uterine/placental/vaginal issues, fetal distress or shoulder dystocia
  • According to MedScape, The leading indications for cesarean delivery are previous cesarean delivery, breech presentation, dystocia, and fetal distress. These indications are responsible for 85% of all cesarean deliveries.

I think that most of us would agree that in a healthy mother and baby, a vaginal birth is the way to go. However, in an effort to “control the situation and avoid complications” or to “avoid the pain” or “avoid going into labor at an inconvenient time”, mothers and doctors often schedule a cesarean section “to be on the safe side”. This is the impetus behind the International Cesarean Awareness Network (ICAN) and its supporters.  ICAN and other organizations hope to raise awareness amongst women that cesarean sections are to be the exception to vaginal birth when it is unsafe for mother and baby to undergo vaginal delivery. And while most of us agree with that statement, thousands upon thousands of women often mistakenly believe that delivering vaginally will be unsafe or them and their babies and opt for the cesarean delivery.

Probably the most common reason for cesarean birth is repeat cesarean delivery. There used to be a saying, “Once a cesarean always a cesarean.” Thankfully this is no longer the case. Because of the risks associated with cesarean sections, more and more practitioners are beginning to look at VBAC (vaginal birth after cesarean section) as an option. One has to understand, a cesarean delivery involves cutting the abdominal and uterine walls, creating defects or weaknesses at the sites of the cuts and places for scar tissue to develop. The greatest concern is that in a VBAC, these areas won’t hold and the uterus will rupture causing hemorrhage and risking the lives of both mother and fetus. However, data is showing that this risk of uterine rupture is not as great as previously thought and that women who have repeat cesarean sectioins are at even greater risks. Additionally, in very healthy women having uncomplicated pregnancies and birthing with a skilled practitioner, VBAC’s are quite safe.

Another common reason for cesarean delivery is “large baby”. This is probably the most disputed reason for cesarean delivery and the most controversial. Who hasn’t heard stories of the 5 foot woman delivering an 11lb baby vaginally, or the 5ft 10 inch woman who had difficulty delivering a 5lb baby and required a cesarean section? Size of the baby is rarely the issue, but more aptly the position of the baby in the pelvis, the shape of a mama’s pelvis and how well mama and baby are faring during the delivery process.

Cesarean sections are also more common during labor inductions.  When labor is allowed to start and proceed spontaneously, babies have time to adapt and progress along the birth canal. Normal birth proponents continually state that when a baby is not ready to be born and labor is induced, the baby is rarely in the correct position in the birth canal, the baby often becomes distressed as a result of the uterine contractions, the labor fails to progress and then a cesarean section is performed.

So how does a mama decide whether or not a cesarean delivery is best for her?

  • Do your research. Know the indications for cesarean delivery
  • Talk with your health care provider. Know (as much as possible) the position of your baby in the uterus, consider the gestational age of the baby
  • Consider your obstetrical history. If you have certain complications, you may be more likely to require a cesarean delivery. Talk with your health care provider to assess your risks.

It’s a really tough decision. Even today, some six years after my last cesarean section, I often wonder if I should have tried to deliver my son. (my second child). But I had a list of obstetrical complications that would have made a VBAC quite risky. For women without my dicey history who are considering a VBAC vs. a cesarean delivery, I say, do your research, “be aware”. Only once you’ve fully informed yourself and spoken with your health care provider can you make an informed decision about whether or not to have a cesarean delivery.

Resources

The International Cesarean Awareness Network (ICAN)

MedScape

NIH Consensus Development Conference on Vaginal Birth after Cesarean: New Insights

The American Pregnancy Association

American Congress of Obstetricians and Gynecologists

About.com

Giving Birth With Confidence

Unnecesarean

My daughter at birth

Mamas on Bedrest: I Am in Favor of A Single Payor Health Care System for the US

March 28th, 2012

We all knew that it was coming. Following the contentious debates over the health care bill and ever since President Obama signed the bill into law, opponents have vowed to fight the individual mandate requiring Americans to buy health insurance or face a penalty and to repeal the law entirely. Cases have been heard in courts around the country and since none of them have come to consensus agreement, the arguments about constitutionality, whether or not the government can make citizens purchase health insurance, whether or not the government can impose a penalty on Americans who don’t purchase health insurance and whether or not that penalty is a tax is being argued before the justices of the supreme court.

The justices first began hearing arguments on Monday, March 26, 2012 and have continued to listen to arguments for three days. The arguments will conclude this afternoon and the justices will cloister together and later render a verdict. The final verdicts and written rationales are expected to be rendered before July of 2012.

I think that few will argue that the health care system in the United States is in trouble and in dire need of an overhaul. The problem is that we as a nation cannot reach a consensus as to what that overhaul should be and how to structure it so that the majority, if not all Americans are insured and have access to quality health care. To date proposed options have ranged from obliterating insurance all together and returning to a fee-for-services system, a national health care system that is funded with taxes but ensures that everyone has access to health care when needed like Canada or in Europe, complete privatization of health care and everyone is responsible for their own insurance or some other as yet undisclosed plan.

I’m going to go on the record and say that I am in favor of a single payer system that gets funded via taxes. Uh, Gasp, what????? Yup, I’ve said it. I believe that the United States should do away with insurance companies and should establish a single payer health care system which is funded by taxes.  Why would I take such a stand? It’s simple. The health of a nation will ultimately determine the wealth of a nation. The United States spends more of its Gross Domestic Product (GDP) on health care than most any other country in the world. Yet, we have the highest rates of preventable diseases such as heart disease and diabetes. We have the highest rates of maternal and infant mortality amongst industrialized nations (and even amongst many “developing” nations) and we have millions of citizens who don’t have access to affordable, quality health care such that when these individuals do get sick, we as a nation end up paying for them with unallocated funds. In a nutshell, we are going broke under our current health care system. Our current national health care spending cannot be sustained. As a nation, once we cannot ensure the health of our citizens, our nation’s wealth-our natural resources of people power, brain power, innovation, technology, agriculture, etc-will all dwindle away. We will dwindle away. It’s all completely preventable. We have to stop this “I’ve got mine, let the other guy get his own” mentality. We are our brothers and sisters keepers. We have to take care of one another.

When I started Mamas on Bedrest & Beyond I was quite ignorant to the plight of many women who were prescribed bed rest and the financial ruin that many families faced as a result of a high risk pregnancy, pregnancy bed rest and intensive care of premature infants. Increasingly, having a family is becoming a luxury only the wealthy can afford. If a woman works in the service industry as a teacher, a care provider, fast food restaurant manager or other such low paying, poorly compensated jobs she literally cannot afford to become pregnant-let alone have a complicated pregnancy. If she goes on bed rest for more than 12 weeks, she risks loses her job and her family is further pushed into financial constraints. Many women are having to choose between having a job and having a family while loss if either is untenable.

I could launch into a diatribe about why we need paid family leave, but I have spoken liberally about that and will continue to do so-just not in this post. In this post, I want to underscore how many women become high risk as a result of not having access to quality, affordable health care early in their pregnancies. Here, I want to underscore the hoards of women who are panicked because they are on bed rest and don’t know how they’ll make ends meet or how they’ll pay their medical bills. And I want to underscore the extraordinary costs associated with the care of premature infants and children. Oh, I could go on and on, but you get the picture. I could talk about the children who don’t receive immunizations because their parents are uninsured and can’t afford them. The women who go without pap smears and pelvic examination, mammograms or birth control because they can’t afford them and are uninsured. Yet we all pay when they become ill or pregnant and require specialized care. I would gladly pay higher taxes so women can have access to birth control pills rather than pay for unintended pregnancies. I would gladly pay higher taxes if it means that all women receive early access to prenatal care so that their pregnancies can start off well and we can potentially avoid preterm labor and prematurity and prolonged NICU stays for these infants. And with the money saved from not having to fuss with insurance claims and administration, I really think that we as a nation really can afford to provide health care to everyone.

For the past 3 days the justices of the US Supreme Court have been listening to arguments as to whether or not the Affordable Care Act and its individual mandate are constitutional and should be upheld. Many Americans want the law repealed and cite “Don’t tell me how to spend my money”. To that I say, don’t ask me for mine or anyone else’s once you get sick. As I see it, we can all pay into the health care pot and share the burden (and actually lower costs). But if you would rather not to contribute to the health care pot, go it alone, have at it. But don’t ask for “your portion” when you’re in need.

Mamas on Bedrest: Would You Abort a Baby with Genetic Defects?

March 16th, 2012

My friend Mollee over at Pregnancy.org posted this piece on her blog.

“Couple Awarded $2.9 Million Dollars for Incorrect Prenatal Diagnosis

In one of the most controversial cases of its kind, a jury in Oregon has just awarded parents Ariel and Deborah Levy $2.9 million in their wrongful birth lawsuit against their doctor…The couple was told that their prenatal tests did not detect Trisomy 21, more commonly known as Down syndrome. However, when their little girl was born, she did in fact, carry the extra chromosome.  The Levys said that they would have terminated the pregnancy had they known that their child would have Down syndrome. “

Wow! All I can say is Wow!

There were so many striking points in this article that I recommend that each mama read the article for herself and draw her own conclusions. Whether or not to terminate a pregnancy is such an intimate, important and often times gut wrenching decision I don’t think any of us could ever know that depths of the decision without being faced with it.

My husband and I faced a similar decision when we began having children. I gave birth to my daughter just weeks before my 37th birthday and I was 40 yrs and 4 months when I gave birth to my son. For this and other medical reasons both my pregnancies were high risk. In particular, I miscarried before each successful pregnancy. When I became pregnant with my daughter and the pregnancy actually progressed, my OB suggested that I have an amniocentesis. I flat out refused.

According to the American Pregnancy Association, Amniocentesis carries a risk of miscarriage of 1/400 women to 1/200 women depending on the facility performing the procedure (Those facilities that perform many amniocenteses have rates closer to 1/400.) As a woman who had already miscarried and now had a “viable” pregnancy, there was no way that I was going to risk the pregnancy by having an amniocentesis. My husband initially wanted the procedure so obviously we were at odds. We met with my OB to get answers in order to make an informed decision.

“An amniocentesis  is a diagnostic test,” she told us. “It will tell us definitively if there is a problem with the baby. However, it is not a therapeutic test, meaning that once we diagnose a problem, especially a genetic problem, we can’t treat it.” With that information, we both decided against an amniocentesis. Neither of us would abort our child, so why risk it? However, we did want to know if there were other, less invasive ways to detect genetic or other developmental abnormalities. Turns out there are several prenatal screening tests that can  give an indication that there may be a problem. Parents can then decide how they wish to proceed.

We had the First Trimester Risk Assessment with both of my pregnancies. High level ultrasounds provided a clear visual of each of my children showing their normal musculoskeletal deveopment (including normal head formation and no cleft palates). Blood tests showed very low risks for genetic abnormalities. This was a great choice for us and provided a high leve of comfort and relief. Other screening tests are available. Do discuss with your OB you options for prenatal screening tests.

I don’t know how I would have responded if one of my children, despite the screening tests, was born with Down’s syndome. I’ve seen so many kids with Down’s Syndrome do so well, yet I know of many others that have chronic health issues, developmental delays and learning disabilities. I don’t think that I would have sued the perinatal group that performed the test or my OB, but who knows? Children with Down’s Syndrome require a lot of additional care that is expensive. Again, I don’t think any of us can predict how we’d react unless we’re in that situation.

I encourage all pregnant mamas and their partners to read the blog post on Pregnancy.org, to read through the references and citations provided here and have a frank discussion with your OB if you have not already done so. As always, knowledge is power and the more you know, the more you can act from a position of strength and wisdom instead of react out of fear and outrage.