Birthing Beautiful Ideas

The March of Dimes has designated November as “Prematurity Awareness Month.”  As part of their campaign to increase awareness about prematurity and its serious risks to newborns, they have called for bloggers to write posts about premature awareness and to publish those posts today, November 17.

Hundreds of bloggers have already written insightful, informative, and moving pieces about prematurity awareness, and many of them have dedicated their posts to those who have been affected by prematurity.

And while some of these bloggers have already touched on the point I am about to make–one that I have addressed briefly in other previous posts–I feel compelled to reiterate one small but important point: namely, that  labor induction and cesarean section performed prior to 39 weeks have been shown to contribute to serious neonatal complications, including (but not limited to) late prematurity and the many problems that accompany it.

In fact, a study published earlier this year in the New England Journal of Medicine concluded that:

As compared with [elective repeat cesarean] births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome (adjusted odds ratio for births at 37 weeks, 2.1; 95% confidence interval [CI], 1.7 to 2.5; adjusted odds ratio for births at 38 weeks, 1.5; 95% CI, 1.3 to 1.7; P for trend <0.001). The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks.

What’s more, a recent article published by MSNBC noted that many hospitals are limiting their birth attendants’ abilities to perform unnecessary inductions prior to 39 weeks because of the extra risks presented to babies (including iatrogenic, or doctor-caused, prematurity).

So if you are planning a repeat cesarean, or if you are considering an induction, and if there are no medical indications for an early c-section or induction, please consider waiting to schedule your baby’s birth until after 39 weeks.  (Or, if possible, consider waiting for labor to begin spontaneously!)

You will do your baby so much good just by waiting those few extra days until s/he is ready to be born.

(To learn more about prematurity in the United States, please visit the March of Dimes’s website.)

Oftentimes when I see anything birth-related covered by the national news, I end up feeling very underwhelmed (to say the least).  One-sided coverage (mostly from ACOG’s perspective), exaggerated risks and benefits of various procedures or processes, and even a blatant lack of research on a given topic all seem to pervade the segments on pregnancy and birth that I’ve seen in recent years.

But the past week has been a relatively good week for transparent and seemingly fair (though, admittedly, not always cheery) coverage of a few birth-related issues.  And in my opinion, each of the following news pieces is worth checking out–not just for the decent news coverage but also for the helpful information.

From CNN

Senior medical correspondent and “Empowered Patient” columnist Elizabeth Cohen examines the relative risks and benefits of VBAC and cesarean section within the context of two current news stories: 1) the fact that some insurance companies have denied women health care coverage after considering their previous c-sections to be “preexisting conditions” and 2)  the story of Joy Szabo, a mother in Arizona who must travel 300 miles to the nearest “VBAC-supportive” hospital just to have her second VBAC (and who was threatened with a court-ordered cesarean by her local hospital if she attempted to have a VBAC there). 

All in all, I am impressed with Cohen’s discussion.  Could she have done a better job of reporting the risk of uterine rupture?  Sure.  (For what it’s wort, the rate of uterine rupture during a VBAC is less than 1% for most women: .4% if labor begins on its own, .9-1.1% if labor is augmented or induced with pitocin, creating a rate of approximately .7% for all VBAC attempts, induced or not.)

But Cohen does a superb job of addressing issues that are often overlooked in the coverage of cesarean sections and VBAC.  For one, she is careful to place the risk of uterine rupture alongside the risks of cesarean section.  This simple exercise in good reporting helps to dispel the illusion that VBACs are a “risky” option when compared with “easy” and “risk-free” cesareans.

In addition, Cohen points out that patient-chosen, non-necessary elective cesareans make up a very small percentage of the cesarean sections performed in the United States.  This is especially noteworthy in light of the fact that some medical professionals (though certainly not all) have often pointed to “too posh to push” cesareans as one of the primary reasons for the nation’s rising cesarean rate.  But their “mother-blaming” (in addition to being inherently misogynistic) simply doesn’t pan out when one considers the relative infrequency with which patient-chosen, non-necessary elective cesareans occur.

You can watch the following video to see more about what Cohen has to say about VBAC, c-section, the related issues:

From MSNBC

The very title of this article left me smiling: “Hospitals to crack down on induced labors.”

An even better title, however, would have been “Hospitals to crack down on UNNECESSARY and EARLY induced labors.”  Because as the article reports (and as studies have demonstrated), these inductions–especially those performed before 39 weeks–can lead not only to iatrogenic (or doctor-caused) prematurity but also increase a baby’s risk of NICU admission and increase first-time mothers’ risk of cesarean section.

So don’t worry–if you and/or your baby’s health requires an induction, hospital regulators and administrators are not going to deny you an induction.  But they may restrict your care provider’s ability to schedule convenience inductions–and that’s all with your and your baby’s health in mind.

From the BBC

And finally, this week the BBC news published an overview of maternal mortality across the world.  In their examination of the United States, they found that:

The US spends more money on mothers’ health than any other nation in the world, yet women in America are more likely to die during childbirth than they are in most other developed countries, according to the OECD and WHO.

The article points to the lack of health insurance and coverage, poverty, the staggering c-section rate, and obesity as potential contributing factors to this sad and disheartening state of affairs.  What’s more, it sheds brief light on the fact that African-American women are “three to four times more likely to die during childbirth than white American women,” even when one compares the outcomes of wealthy black women to wealthy white women.  (Notably, many people have speculated that the stress of racism has a significant effect on the disparity of maternal outcomes between black and white women in the United States.)

But what this article also illuminates is the fact that we must demand better maternity care for women in the United States (and in all countries, for that matter).  We need better prenatal care (which should include not offhand castigations about “gaining so much weight” but respectful and helpful nutritional counseling from the first trimester and beyond).  We need better labor and delivery care (with more emphasis on evidence-based maternity care and not on unnecessarily intervention-heavy birth).  We need health care coverage for all pregnant women (period).

At least that’s what the BBC article illuminated for me!

(For more on issues of maternal mortality in the United States, please see Ina May Gaskin’s Safe Motherhood Quilt Project.)

“At the end of the day, it doesn’t matter how the baby came out.  All that matters is that you have a healthy baby.”

It’s that dreaded “healthy baby line.”  The one I’ve written about before.  The one that others have addressed with admirable sensitivity and eloquence.

And I’ve been thinking about that line in a relatively new light lately.

My general position on the “healthy baby line” hasn’t changed.  I still think these sorts of statements are hurtful and demeaning and insensitive to women’s experiences.  To be fair, I also don’t think that people generally intend for these statements to be taken as such.

But in addition to the aforementioned response that I’ve given to the “healthy baby line”–a response that focuses on the emotional aspects of birth and new motherhood–I’d also like to add this point: Healthy babies do matter.  And that’s why I (and others) care so much about how they come out.

This is because unnecessary birth interventions that interfere with how babies “come out” can pose additional risks to moms and their babies.

This is not to say major birth interventions such as induction of labor or cesarean section are so risky that they should never be used.  To the contrary, when these interventions are necessary and/or medically indicated–for example, when a woman has a cesarean section for placenta previa, or when a woman’s labor is induced because of preeclampsia–they are wonderful and even life-saving uses of the medical technology that is currently available.

But when these interventions are used in the absence of necessity or medical indication, some parents may decide–and have the right to decide–that the possible benefits of these interventions might outweigh their risks.

Notably, some of these risks are relatively small.  Some of them may even be risks that moms and/or their partners examine and pore over and say to themselves, “You know, I think that the convenience of having an elective induction still outweighs the risks that it presents, and I am willing to take on those extra risks.”

And in these sorts of cases, they’ve made an informed decision.  And informed decisions–informed consent–are something that I not only respect but also champion as a fundamental right for all medical patients.

But before a parent can make an informed decision about unnecessary induction and/or cesarean section, they should know the following:

According to Childbirth Connection’s systematic review of the comparative risks of cesarean section and vaginal birth, cesarean section poses the following extra risks* to both mothers and babies:

• Physical problems in mothers: Compared with vaginal birth, cesarean section increases a woman’s risk for a number of physical problems. These range from less common but potentially life-threatening problems, including hemorrhage (severe bleeding), blood clots, and bowel obstruction, to much more common concerns such as longer-lasting and more severe pain and infection. Even after recovery from surgery, scarring and adhesion tissue increase risk for ongoing pelvic pain and for twisted bowel.
• Hospitalization of mothers: If a woman has a cesarean, she is more likely to stay in the hospital longer and is at greater risk of being re-hospitalized.
• Emotional well-being of mothers: A woman who has a cesarean section may be at greater risk for poorer overall mental health and some emotional problems. She is also more likely to rate her birth experience poorer than a woman who has had a vaginal birth.
• Early contact with, feelings toward babies: A woman who has a cesarean usually has less early contact with her baby and is more likely to have initial negative feelings about her baby.
• Breastfeeding: Recovery from surgery poses challenges for getting breastfeeding under way, and a baby who was born by cesarean is less likely to be breastfed and get the benefits of breastfeeding.
• Health of babies: Babies born by cesarean are more likely to:
  • be cut during the surgery (usually minor)
  • have breathing difficulties around the time of birth
  • experience asthma in childhood and in adulthood.
• Future reproductive problems for mothers: A cesarean section in this pregnancy puts a woman at risk for future reproductive problems in comparison with a woman who has a vaginal birth. These problems may involve serious complications and medical emergencies. The likelihood of experiencing some of these conditions goes up sharply as the number of previous cesareans increases. These problems include:
  • ectopic pregnancy: pregnancies that develop outside her uterus or within the scar
  • reduced fertility, due to either less ability to become pregnant again or less desire to do so
  • placenta previa: the placenta attaches near or over the opening to her cervix
  • placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus
  • placental abruption: the placenta detaches from the uterus before the baby is born
  • rupture of the uterus: the uterine scar gives way during pregnancy or labor.
• Concerns about babies in future pregnancies: A cesarean section in this pregnancy can affect the babies of future pregnancies. Studies have found that they are more likely to:
  • be born too early (preterm)
  • weigh less than they should (low birthweight)
  • have a physical abnormality or injury to their brain or spinal cord
  • die before or shortly after the birth

And in addition to the general risks of induced labor (such as an increased risk of NICU admission, forceps and vacuum-assisted delivery, and abnormal fetal heart rate), the use of synthetic oxytocin (or pitocin) itself carries a number of risks of which parents should be aware.  As reported in the RxList Drug Guide, pitocin can lead to the following adverse reactions in a mother:

Anaphylactic reaction
Postpartum hemorrhage
Cardiac arrhythmia
Fatal afibrinogenemia
Hypertensive episodes
Nausea
Vomiting
Premature ventricular contractions
Pelvic hematoma
Subarachnoid hemorrhage
Hypertensive episodes
Rupture of the uterus

Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.

And according the same RxList Drug Guide, the pitocin can lead to the following adverse reactions in the fetus or neonate:

Bradycardia
Premature ventricular contractions and other arrhythmias
Permanent CNS or brain damage
Fetal death
Neonatal seizures have been reported with the use of Pitocin (all due to induced uterine motility)

and:

Low Apgar scores at five minutes
Neonatal jaundice
Neonatal retinal hemorrhage (all due to use of synthetic oxytocin in the mother)

It should go without saying that none of these lists are meant to frighten anyone about labor induction or cesarean section.  To reiterate, these invertentions can be wonderful, life-saving uses of medical technology.  What’s more, there are ways to make the experience of these interventions more mother-, baby-, and family-friendly.

Nonetheless, the risks that these interventions pose to mother and baby demonstrate just why it does matter how a baby “comes out.”

And that’s because how a baby comes out can have a significant affect on how healthy that baby is.

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*Worth noting is that the Childbirth Connection’s systematic review of cesarean section and vaginal birth did find the following increased risks of vaginal birth (as compared with c-section): an increased incidence of perineal pain and incontinence for mothers, and increased risk (though still low risk) of nerve injury in babies.

I have now written five posts on “VBAC scare tactics,” or “the (outrageous) statements [that] are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.“  I plan to write more–many more, in fact, because there are loads of unfounded “reasons” that OBs (and some midwives) give to women each day in order to deter these women from choosing a vaginal birth after cesarean rather than a repeat cesarean.

In each of my posts on VBAC scare tactics, I identify one particular scare tactic, supply a list of questions that a mother can ask her care provider in response to this scare tactic, and then provide an analysis and/or summary of the research that either challenges or even debunks the scare tactic and its insinuations.

Yet nowhere do tell a mother that she should leave her scare-tactic wielding care provider.

Nowhere do I tell her that should wait for labor to begin spontaneously.

And nowhere do tell a mother that she should attempt an intervention and drug-free childbirth.

And this is despite the fact that I think that these are wise and excellent choices for the vast majority of all births, and despite the fact that I think these choices give a woman the best chance of having a successful VBAC.  (And, let’s be honest, it’s also because I’m under no impression that someone is going to come across my blog and say, “Hey, that gal at Birthing Beautiful Ideas told me to do it, so by God, I’m gonna!”)

Nonetheless, despite what I think is wise and excellent and VBAC-success-producing, I also think that women should feel empowered to make their own decisions about the births of their babies.  They should be able to make their decisions autonomously, and from evidence and research that they have read and/or discovered.  And when a VBAC-supporter or natural-childbirth-supporter or anyone is too heavy-handed in his or her advice, then this heavy-handedness can diminish a woman’s sense of empowerment and autonomy.  It can even influence a woman to refrain from looking more closely at whatever it is that the advice is pertinent to.

(For what it’s worth, I think that my birth experience with A was so spectacular because I owned every decision I made about the birth, and I made those decisions from a place of empowerment and autonomy, from a place where no one ever told me categorically what I should or should not do.)

Even so, I think that it is reasonable for me to “lay my cards on the table,” so to speak, and elucidate what I think a woman should consider:

• If one’s care provider is hurling “VBAC scare tactics” left and right, then one should consider finding a new care provider.  I did.  I did it.  At nearly 37 weeks into my pregnancy no less.  And it was terrifying, and I cried for days…and I have never once regretted my decision.  Because A’s birth would have been so, so different–and certainly not so amazing and transformative–if I hadn’t reached inside myself and culled up all of my strength and stood up to an obstetrician who tried to coerce me into an unnecessary repeat cesarean.  (For those of you who do wish to transfer to a new care provider, here is good resource containing questions that you can ask when interviewing your new care provider.)

• Unless an induction is medically indicated or necessary, I think that all pregnant women should consider waiting for labor to begin spontaneously.  There are  real risks associated with inductions, whether or not the mother’s uterus is scarred.  There are also real disadvantages to induction since the mother must be hooked up to an IV and to continuous electronic fetal monitoring, thereby limiting her ability to change positions as a comfort measure and to use gravity as a way to “bring the baby down.”  What’s more, synthetic oxytocin (or pitocin) interferes with the body’s ability to release endorphins that can help to counteract the pain of labor, and it intereferes with the body’s own release of natural oxytocin, which helps to promote the mother’s bonding with the baby after birth.  So while induction may be a reasonable and even necessary way for labor to begin–even for a mom attempting VBAC, despite the extra risk that induction presents–there are numerous reasons that should give a mother pause before consenting to a non-necessary induction.

• And finally I think that all women should consider attempting an intervention-free and drug-free childbirth.  I’m certainly not saying that all women should attempt a “natural childbirth.”  But I think that all women should at least consider them.  Weigh the pros and cons of pain medications and interventions.  Or at least look at their options.  Or KNOW that there are options!   (They’re not for everyone, of course, and there are definitely, without a doubt, times and places for pain medications and medical interventions during birth–just so long as a mother can, if possible, participate in the decision to use those interventions and can make that decision from a place of empowerment and autonomy.)  But back to why women should at least consider or research a natural childbirth…  My reasons for this stretch beyond the multitude of physical and emotional benefits of a drug-free birth for both mom and baby.  They stretch far beyond the risks that accompany the various medical interventions used during labor and delivery.   For in addition to these reasons, I think that a drug-free and intervention-free birth can be one of the most amazing, inspirational, empowering, and transformative events in a mother’s life.  Especially when it is borne from a place of education and empowerment and autonomy and preparation.  And it’s not just for granola-crunchy and/or birth junkie types either–just check out Heather B. Armstrong’s most recent post about the natural birth of her second daughter over at dooce.com.  (I, like many others, have been stalking her blog every day for the past couple of weeks to get this latest installment of her birth story.)  As Ms. Armstrong so wisely says, for those of us who work toward and research about and are lucky enough to have a natural childbirth, these births have the ability to change our perspective on our entire lives.

And that’s something that every woman should know is possible.