Cesarean Section

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: Pregnancy, Labor & Delivery Complications Can Have Longstanding Effects

April 9th, 2012

Every now and then I’ll read something and ask, “What were they thinking?”

Such was the case when I read an article/blog post on FitPregnancy.com. In what I am assuming was an attempt to mitigate fear and worry in pregnant women about to deliver, Marjorie Greenfield, M.D., a professor of OB-GYN at Case Western Reserve University School of Medicine was quoted as saying,

“Most ‘complications’ are irrelevant. They have no impact on the health of the mother or the baby.”

I found this statement appalling because many complications have longstanding effects-both physically and emotionally- on mothers and their children. As a woman who had significant intra partum bleeding (I use the word hemorrhage but that isn’t the official notation in my chart) my delivery “complication” had significant effects on me, my daughter (who spent 10 days in the NICU) and my husband who witnesses this traumatic birth.

Pregnancy complications have a significant impact on mamas and this is especially true for mamas on bed rest who have an increased risk of complications during labor and delivery (in addition to their bed rest complications) and who are at increased risk of post partum mood disorders. Mamas experience a wide range of feelings and emotions. Speaking from personal experience, I felt like my body failed me and my daughter because my delivery was so complicated and resulted in my daughter landing in the NICU. I experienced a profound sense of loss. My daughter never stayed in my room with me and I felt robbed of that experience. I hurt. I had delivered via c-section and on top of everything else, my body simply ached.

I felt “wrong” on many levels.  I had a scheduled c-section. I had done a lot of research and saw that many “authorities” extolled the virtues of vaginal birth. Yet because of my reproductive history, I was told my body was unable to deliver vaginally without a significant risk of uterine rupture. My OB, husband and I discussed my options at length and decided on the c-section. After my delivery, I questioned my decision to have a scheduled c-section thinking perhaps if I had delivered vaginally my daughter and I would have fared better. I felt I had let may daughter down and that it was somehow my fault that she ended up in the NICU. I also felt that I had let my husband down. I had a tremendous amount of guilt that stayed with me for a long time.

Amazingly, I didn’t suffer from post partum depression. Amy Przeworski, PhD is an associate professor of psychology at Case Western Reserve University in Cleveland, Ohio who specializes in research of post partum depression and post traumatic stress symptom. She too read the article on FitPregnancy.com and penned a very well delineated response entitled The Relevant Woman, The Psychological Effects of Pregnancy Complications. Her blog post appears on Psychologytoday.com, Don’t Worry Mom,  Coping with Anxiety in Families. She presents 3 important points in why pregnancy and delivery complications are “relevant”.

1.  Labor and delivery complications are not irrelevant. Women who experience labor and delivery complications are at an increased risk for postpartum depression and often experience symptoms such as a sad mood that lasts for as long as two weeks, decreased interest in activities, difficulty sleeping, fatigue, worthlessness or excessive guilt, feeling slowed down or agitated, difficulty concentrating, and even thoughts of suicide.  Women who have experienced labor and delivery complications often report feelings of failure and incompetence as a woman and a mother.  Further, labor and delivery complications can have a real psychological impact on the mother, the mother’s relationship with her significant other, and her relationship with the baby.

2.  Complications don’t just sound scary, they are scary. Labor and delivery complications are traumas and can cause post-traumatic stress disorder symptoms, such as emotional numbing, distress at reminders of the trauma, avoidance of thoughts and feeling associated with the trauma, inability to recall aspects of the trauma, decreased interest in activities, feeling detached from others, difficulty falling or staying asleep, irritability, and difficulty concentrating.  Women can dissociate during these events, mentally checking out of them when the terror overwhelms them…The experience is also terrifying for significant others who helplessly watch their wives and girlfriends endure invasive and painful procedures or who fear for the life of their baby. (Which is exactly what happened to my husband!!

3.  Isolation. Women often do not talk about their psychological reactions to the complications, experiencing shame that they have not “gotten over it” and continued feelings of failure as a mother because of their distress. Feelings of isolation and inferiority to other women who had “normal” deliveries are common. Few women who experienced complications are made aware of the high rates of postpartum depression and posttraumatic stress symptoms following labor and delivery complications. This contributes to women’s views that they are alone or that there is something wrong with them for continuing to experience distress after something as common as a C-section.

While I appreciate FitPregnancy.com’s attempt to give mothers reassurance that their labors and delivery are most likely going to progress just fine, this isn’t always the case. Pregnancy complications can have longstanding effects on a mother, her partner and her baby. Mamas need to have support, information about potential post partum depression signs and symptoms and resources quickly at hand to help.

If you had a complicated pregnancy,  here are some resources that may be helpful to you.

Definitions of post partum mood disorders

Helpful Blogs and Websites

Support for Birth Complications

Depression in Dads

Mamas on Bedrest: Pain Management in Labor-Medical vs Non-Medical Therapies, A Review of the Evidence

March 19th, 2012

Bedrest Coach Darline Turner-Lee takes a look at a literature review,  “Pain Management for Women in Labour: An Overview of Systematic Reviews”. In the review, researchers evaluated several studies in the Cochrane Review to looked at the efficacy of epidural and opiod pain management during labor vs non-medical pain management such as relaxation, biofeedback, acupuncture, water immersion, hypnosis and others.

What researchers found is that while epidurals and opiod medications do effectively manage pain, side effects included more instrumentation during vaginal births, more cesarean sections for fetal distress, low blood pressure, more prolonged leg numbness, fever and urinary retention. Women who received inhaled analgesia were more likely to experience nausea, vomiting, dizziness and in some cases itching. Such adverse results were not experienced with the alternative pain management methods and women reported feeling more in control and more satisfaction with their childbirth experience when alternative pain management methods were used.

Bedrest Coach Darline Turner-Lee reiterates as she reviews this data  that women who wish to utilize an alternative form of pain management should discuss their plans with their health care provider. They should not simply assume that the alternative method is less effective and only consider medical pain management. This study does not say this! She also suggests that women consider using multiple forms of pain management, i.e. relaxation/biofeedback in addition to an epidural. Regardless of the method of pain management employed, women should be well informed about as many pain methods as possible to make a wise choice for their pain management needs. And whatever pain method a woman chooses for labor and delivery, she should be adequately educated about the method and train with a skilled practitioner.

Citation

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2.