Cesarean Section

Mamas on Bedrest: Should I have tried vaginal birth?

February 15th, 2012

My daughter’s birth was traumatic. Born via an “emergent” cesarean section, she was in respiratory distress when she was delivered and I began to bleed profusely.

We had planned to deliver my daughter via cesarean section at 39 weeks. My history of uterine fibroids and subsequent myomectomy made it risky for me to deliver vaginally according to my obstetrician and the fertility specialist who had performed my surgery. The cuts to my uterus put me at risk for uterine rupture.

But I always wondered if it may have been better to deliver her vaginally. I went into labor at 36 weeks and 6 days after weeks of “rumbling” (now known to be contractions) early in the morning. Throughout the morning I’d have a contraction, stop what I was doing, let it pass and then proceed. By mid afternoon, the contractions became regular and prolonged. I went to see my OB and when I had a 2 minute contraction that dilated my cervix 2 cm, I was admitted from her office.

When my daughter was born later that evening, she was only 5 lbs 3 oz and 18 inches long. I’ve always wondered if I shouldn’t have pushed her out. She was a tiny little thing and it’s hard to believe that a vaginal delivery could have been more traumatic than the scrambling that occurred after she was born due to my “profuse bleeding”. (They didn’t officially call it hemorrhaging, but I know my OB had a tough time closing me up because every time she tried to stitch, my uterus bled even more.) I’ve also wondered if the push through the vaginal canal may have in some way squeezed fluid out of her lungs and saved her the 10 day NICU stay for respiratory distress.

Seems like my musings may have in fact been correct. At the 32nd Annual Meeting of the Society for Maternal Fetal Medicine, researchers from Johns Hopkins University found that cesarean delivery provides no benefit for premature infants who are small for gestational age. According to a report in MedScape OB/GYN News,

Clinicians have commonly recommended cesarean delivery for infants who were premature and showed intrauterine growth restriction because it was considered more protective of higher-risk neonates than vaginal delivery.

However, a new study of neonates who were small for gestational age showed that cesarean delivery did not have fewer complications, and in fact had an increased risk for respiratory distress.

“I suspected there might be some benefits to each type of delivery, but it was a surprise to see no benefits…for [cesarean delivery], while there was a benefit for vaginal delivery in terms of less respiratory distress,” lead author Erika F. Werner, MD, MS, from the Department of Gynecology and Obstetrics at Johns Hopkins University in Baltimore, Maryland, told Medscape Medical News.

Dr. Werner and her colleagues also found other surprising outcomes as a result of cesarean delivery of premature, small for gestational age infants,

  • Cesarean delivery did not result in a reduction in the complications that have been perceived as risks with vaginal delivery
  • There is no reduction in neonatal death in infants born vaginally (as has been believed).
  • The odds of developing respiratory distress syndrome were 30% higher with cesarean than with vaginal delivery. The rate remained higher after controlling for factors such as the mother’s age, ethnicity, education, prepregnancy weight, diabetes, hypertension, and gestational age at delivery.
  • Infants delivered by cesarean had increased odds of having a 5-minute Apgar score below 7. No difference was seen after adjustment for confounding factors.
  • Cesarean delivery is associated with increased likelihood of future cesarean deliveries.

This is really important information. So often when a mama is having complications, the immediate medical response is immediate cesarean delivery to “protect” the health of mama and baby. Well, according to these findings by Dr. Werner and her colleagues, this is not at all the case. According to this report, the study was well constructed and had a hearty sample size such that the results are valid and able to be extended to the broader population.

So would this new information have applied to my daughter’s delivery? Technically speaking, my daughter was not small for gestational age, she was just small. Had she gone to term my OB reassures me she would have been closer to 7 lbs. She has no developmental delays or problems, yet does have asthma. Is this in fact due to her delivery? Both my husband and I have asthma histories and my husband’s history is quite severe. So what’s to say her asthma isn’t genetic? And who’s to say that my uterus wouldn’t have ruptured from the previous surgical cuts andscarring? Hindsight is in fact 20/20. But I will always wonder, “What if I had delivered her vaginally…?” Maybe I could have delivered my son vaginally as well!

For you Mamas on Bedrest who may be wondering if you should have a cesarean section, we can only suggest that you have a frank discussion with your doctor about these research findings and if medically reasonable, consider a trial of labor.

Note: This post was written based on information in the MedScape News, OB/GYN and Women’s Health, Society for Maternal-Fetal Medicine 32nd Annual Meeting. Nancy A. Melville was the author of the report.

Mamas on Bedrest: HHS offers $40M in grants to reduce preterm births!

February 10th, 2012

“To help reduce the increasing number of preterm births in America and ensure more babies are born healthy, HHS Secretary Kathleen Sebelius announced more than $40 million in grants to test ways to reverse that trend, as well as a public campaign to reduce early elective deliveries.”

Thus begins the February 8, 2012 press release issued by the US Department of Health and Human Services announcing the $40Million grant program, The Strong Start Initiative.  Strong Start is a joint collaboration between Centers for Medicare & Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), the Administration on Children and Families (ACF), and outside groups devoted to the health of mothers and newborns. (i.e. The March of Dimes, the American College of Obstetricians and Gynecologists (ACOG), the National Partnership for Women and Families, the Society for Maternal and Fetal Medicine, American College of Nurse Midwives, Childbirth Connection, Leapfrog Group, and the National Priorities Partnership convened by the National Quality Forum and others.)

The mission of  The Strong Start Initiative is two-fold:

  1. A test of a nationwide public-private partnership and awareness campaign to spread the adoption of best practices that can reduce the rate of early elective deliveries prior to 39 weeks for all populations; and
  2. An initiative to reduce the rate of preterm births for women who are at-risk for preterm birth and covered by Medicaid through testing enhanced prenatal care models.

According to the HHS press release,

“More than half a million infants are born prematurely in America each year, a trend that has skyrocketed by 36 percent over the last 20 years.  Children born preterm require additional medical attention and often require early intervention services, special education and have conditions that may affect their productivity as adults.

The funds will be awarded to organizations and providers that serve women on Medicaid and will be used to test and implement treatments and protocols that will reduce preterm birth and improve outcomes amongst this population. This is great news for such organizations as Centering Healthcare, CommonSense Childbirth, The International Center for Traditional Childbearing and The Indian Health Services and others which serve large populations of women on Medicaid. These organizations, with their proven methods of prenatal care and lower incidences of complications and preterm births are poised to teach the rest of the health care industry how to provide care to women in a compassionate and culturally sensitive manner all the while improving outcomes.

In addition to preventable preterm births, the Strong Start initiative will also focus on reducing early elective deliveries, which can lead to a variety of health problems for mothers and infants.  Up to 10 percent of all deliveries are scheduled as induced or surgical deliveries before 39 weeks that are not medically indicated. It has been well established that elective delivery before 39 weeks gestation is asssociated with increased complications to both mother and baby in the immediate intrapartum and for many years post partum.  The Strong Start Initiative seeks to significantly reduce the incidence of elective preterm birth and its associated morbidities in mothers and infants.

Finally, The Strong Start Initiative is poised to save money for the health care system. It is estimated that medical care in the first year of life for preterm babies covered by the Medicaid program averages $20,000 compared to $2,100 for full-term infants.  Medicaid pays for slightly less than half of the nation’s births each year.  Even a 10 percent reduction in deliveries occurring prior to 39 weeks would generate over $75 million in annual Medicaid savings. Such savings could be poured back into the Medicaid program to further the health of its recipients and reduce the ever escalating costs of health care in the Medicaid population.

References

The US Department of Health and Human Services

The Center for Medicare and Medicaid Innovation

Mamas on Bedrest: Don’t Miss the Boat! There is no shame in “Assisted” Childbirth

November 14th, 2011

Click to take the postpartum depression survey conducted by Case Western Reserve University http://filer.case.edu/~axp335/postpartdep.htm Thank you very much for your consideration.

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A man was advised to leave his home as a storm was coming and everyone was to evacuate. He refused, but as the storm swelled, he found himself trapped. In an effort to “go above the rising waters”, he climbed up on his roof and begged God to help him. Not long after, a boat came by. The driver told the man to climb in and he’d take him to safety. The man refused saying, “God is going to save me.” The man in the boat continued on. After another couple of hours with the water reaching the eaves of his roof, the man again pleaded, “God, Please Save Me!” Then Emergency rescue personnel arrived and offered to help the man down and take him to safety. Again, he refused stating, “God is going to save me.” Shortly thereafter, the man perished. When he arrived in heaven, he asked God, “God, I begged and pleaded for you to save me. Why didn’t you?” God replied, “I sent you a man in a boat and a rescue squad, what more did you want?”

As humans, we often question and wonder why things happen the way that they do. When I was struggling to have my children, I often cried out to God, “Why can’t I have my children normally like every one else?” Normal is a very relative term.

There is a movement within the birth world to “return birth to its natural state”. I’m all for that. But not all women are going to be able to have the picture perfect pregnancy and birth. Some of us will require medication to become pregnant. Some of us, like me, will require medication (progesterone in my case) to remain pregnant. Others will require assistance to deliver their children. For example, my sister was a preemie born at 6 1/2 months. When she was having her children, she never went into labor. Her obstetrician “learned” (and I have no idea how they figured this out) that she did not receive the “signals” from her babies that would initiate labor. They summized that due to the fact that she was born early certain systems didn’t develop. (She was also born without a common Bile duct, so when she had her gall bladder out, they had to “reconstruct” one for her!) No matter what the reason, she has two healthy grown men now, thanks to “God’s provision” in the form of obstetrical care.

Sometimes life just doesn’t go as planned.  I am so thankful that there are skilled physicians because without them, I would not have my children. While I wonder about the effects of bed rest on a mama’s body, I also know that in certain cases, it is the one thing standing between life and death for both mother and baby. We do far too many cesarean sections in this (United States) country, yet, had I even tried to deliver my daughter, she likely would not have survived, I likely would have hemorrhaged to death and my son wouldn’t exist either. Three people now live and are able to bless this world because there are skilled physicians who intervened on our behalf. They were blessed with skills. We are blessed with life.

Recently I posted a message about classes that I am offering for mamas on bed rest. I got this response from a CPM (Certified Professional Midwife):

I don’t believe in bedrest, so none of my clients would be on it. I believe it only prolongs the inevitable. Barring an incompetent cx, if the baby is healthy, it will stay in until its ready, if its not, might as well let nature take its course and get it over with.

Wow. That’s all that I can say. According to this woman, nature will always work and when it doesn’t, we should just let it go. I am here to say that I wholeheartedly disagree!! For me, the difference between having two healthy children and losing two pregnancies was progesterone. The difference between hemorrhaging to death and surviving were the skillful hands of my obstetrician who was able to manage my bleeding so that I live today! The difference between many women having children and not is the skills and care that many obstetricians and reproductive endocrinologists provide for them. So now it is wrong, somehow “unnatural” for those of us who need that assistance to forgo it, demanding instead “God’s provision in the form of a “natural” pregnancy and birth?

Every one is entitled to their opinion and this CPM is certainly entitled to hers. But I want to reach out to Mamas on Bedrest and to mamas who may not be on bed rest, but needed “a little help” to conceive or to deliver. There is no shame in assisted reproduction or in assisted childbirth! I am sure that like me, many of you prayed long and hard for your children. Are we now to refute them or the methods used to get them here? Of course not!

This woman’s words struck a cord in me because I have had many people comment that I am helping or encouraging women to go against nature. I totally disagree! I believe that if there is a path to your heart’s desire that is legal and effective, Take it! If I can help a woman to have a healthy child by supporting her through the tough patches, then I am going to do it. I see this as no different than helping families with children with special needs or helping a person with an illness manage it so that they can live a quality life. I know that I am speaking to the choir here, but for those of you feeling “less than” because you did not conceive naturally or deliver vaginally, look at it this way,

At least you didn’t miss the boat!!

Please share this with mamas who may be feeling “less than” because they had “help” having their children. If you liked this post, subscribe to this blog via the RSS feed button in the upper right hand corner of this page. Interact with us on Twitter (@mamas on Bedrest) and on Facebook.