Cesarean Awareness Month
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Sweet Peas, Pods & Papas: All About Birth, B@@bs & Babies

Cesarean Awareness Month

In honor of Cesarean Awareness Month, I am going to close out this month’s posts with some information on cesareans.  I am not going to write a lot on how to avoid one in the first place or the specifics of a Vaginal Birth After Cesarean (“VBAC”) since there is already a wealth of information at the International Cesarean Awareness Network (“ICAN”) and Childbirth Connection websites. At the end of the post you will find some good links for more detailed information.

Instead I will offer an introduction to the topic for people who are not aware that cesareans are performed at an alarming high rate, a quick look at causes and precautions, and some insights on what I have learned this week by attending meetings. 

Here is a brief introduction:
In this country, the cesarean rate in 2009 was 32.9%.  It means that over 1.4 million women and families welcomed their children into the world via a surgical procedure.  It marked the 13 consecutive year of a rise in cesarean rates in the United States.  For a look at cesarean rates by the numbers, click here.
 
The World Health Organization recommends that the cesarean rate should be around 15% (See Reference 1 below).  This is what it estimates to be the more accurate percentage of instances when performing an operation instead of allowing for a vaginal birth saves a mother and/or child’s life.
 
So are all the cesareans performed in the United States life saving?  Here is a look at how we rank internationally: the “World Health Statistics 2010 identified 33 countries with lower maternity mortality ratios than the United States, while 37 countries had lower neonatal mortality rates, 40 had lower infant mortality rates...” (2)
 
So working strictly off the numbers, our predominantly medically managed and intervention based hospital model (which includes a high incidence of cesareans) does not equate to a better outcome for mothers and babies.  It is quite shocking to realize that some third-world countries have much better outcomes with their “primitive” approach to labor and birth in comparison to our “advanced” approach.
 
Dr. Berman, who sits on the board of the American Academy of Husband-Coached Childbirth®, taught me a healthy respect for what a cesarean really is as opposed to how it is perceived in today’s society.  We had the privilege of hearing him speak at our training in Anaheim.  According to him, if you were to sustain the injuries and the trauma associated with a cesarean surgery outside of the operating room, you would have a fatal injury that very few people could survive.  Cesareans are a surgical procedure and carry all the risks associated with surgery (see link list below).
 
Causes and Thoughts on Preparation:
According to The Academy of Husband-Coached Childbirth®, here are the six leading causes of cesareans:
     -       Inability to relax
     -       CPD: Cephalo-Pelvic-Disproportion ~ the baby’s head is too big
              to fit through the mother’s pelvis
     -       FTP: Failure To Progress ~ the mother’s dilation doesn’t match
              the care provider and/or hospitals expectations, protocol or
              practice
     -       Fetal distress
     -       Prolonged labor
     -       Pain
 
How do you prepare yourself and avoid facing these in your labor?

Inability to relax: attend a childbirth preparation class, like The Bradley Method® series, that teaches you about the process of labor so that you are educated.  Knowledge eases fear and has the potential to break the Fear-Tension-Pain cycle that stops relaxation.  The Bradley Method® also prepares couples with twelve different relaxation techniques – if a couple attends classes and does their homework, they will have several tools to use until they find the one that best relaxes the mother and allows her body to work with her labor.
 
CPD:  True CPD is a real medical complication.  It is usually found when a woman has experienced severe malnutrition.  However, it cannot be accurately diagnosed until a mother has had a trial of labor, which has a very ambiguous definition (3).  Know how long your care provider will let you labor before coming to this conclusion. 
 
In addition, we need to remember and trust that our pelvis is a comprised of moving parts, and that there are hormones made by our bodies that relax the tendons so that those parts can stretch and mold with our babies, and then return back to the proper alignment and shape after we give birth.  We also need to remember that labor works best with gravity.  If a mother has been lying on her back and fighting gravity, she will be more tired and her body will be less likely to function as it was designed to do.
 
If you hear this term in relation to your labor, ask for the time (as long as mom and baby are not at risk) to try different positions and see what your body is capable of.   Chances are good of a vaginal birth if you get a mother off of her back and into positions that open the pelvis and work with gravity, i.e. walking, upright and squatting positions.  With these, her pelvis will be more likely to open and expand to welcome her child vaginally.
 
FTP: This is a clear case where knowing what your care provider and birthplace consider “normal” is of utmost importance.  If one or both of them expect all moms to deliver by a certain timeline, find another care provider or birthplace.  All bodies are unique and all babies are unique.  Each labor will be exactly as long as it needs to be – and if you are expected to fit into a particular timeframe or else face the knife, trust your instinct that is telling you that this is an unrealistic expectation.
 
Fetal Distress:  This is another situation that could be a real medical complication.  Fetal monitors were designed to be used intermittently, and specifically in instances when distress was suspected.  Instead, monitors are used as a continuous procedure unless you make a specific request in your birth plan to have it otherwise.
 
The word “labor” applies to both the mother and the baby – and as we all know, hard work causes stress.  Most babies will handle the stress of labor beautifully when the mom has stayed low-risk and eaten a well-balanced diet throughout her pregnancy. It is important to read and educate yourself on what true fetal distress is and what the causes are so you can make an informed decision if you start to hear that term during your labor.
 
If fetal distress is indicated solely due to the tape the machine is spitting out, the first thing to do is ask if you have time.  If the clear and urgent answer is no, then you decide what you want to do for a Healthy Mom, Healthy Baby outcome.  If there is time, then you can ask for a second opinion, and/or ask for them to listen to the baby by other means, such as a fetoscope or a Doppler.  The monitors can give false readings by the simple fact that they are just a machine interpreting the signs from the baby instead of a trained set of hands and a human ear that feels and listens to the baby.
 
Prolonged Labor: This is a situation when knowing what your care provider or birthplace considers “prolonged”, and also when having a supportive coach and a support team makes a huge difference.  The mother and coaches attitude about having a prolonged labor will affect how a choice for or against a cesarean.  The questions to consider here are: Is the mother okay? Is the baby okay? Do we believe that our labor is what our baby needs?  Are we willing to give baby the time he or she needs to be born? What else could we do/try before we agree to a cesarean?
 
Every couple will make their own choice under these circumstances.  Their list of things to do or try before they accept a cesarean will depend on their training and the experience of coach or any assistant coaches the couple has with them.  If the mom and baby are not in distress after a prolonged labor, there is no right or wrong answer in this case – it is entirely up to the parents to decide which path they want to choose.  If the answer is yes to either the mom or baby showing signs of distress, then the answer is quite clear when you are presiding goals are Healthy Mom, Healthy Baby.
 
Pain: I would be lying to you if I told you that childbirth is painless.  However, the pain is bearable when you focus on the result of the work you are doing and when you are surrounded by the love and care of your coach and any assistant coaches.  There are times when the pain changes, and an excruciating pain that doesn’t break and/or that is accompanied by bright red blood is a true complication. It could be a life-threatening complication like placental abruption or a uterine rupture.  These clearly indicate a cesarean to attempt to save the life of the mother and the child.
 
If the pain increases in intensity, but it continues to ebb and flow with the strength of the contractions, then the team needs to evaluate if maybe the baby is malpositioned and needs to be encouraged to move again.  The other cause of intense yet manageable pain could indicate an emotional component of labor that the mom needs to address before labor can resume its normal course.
 
What I gleaned from meetings I attended week:

Here are some snippits of conversation that gave me points to ponder:
In response to some moms saying they went to the hospital for the safety net, one VBAC mom asked “Is going to the hospital really “safe” if it increases your chance of having a cesarean by 33%?”
 
“Having a cesarean means that you are going to fight for the right to birth vaginally for every birth thereafter.”
 
For a good list of how to avoid an unnecessary cesarean, see the link list below.
 
Here is a collection of recommendations from women at the ICAN meeting and the East Valley Birth Circle who had successful vaginal births after cesarean (VBAC):
 
The answers you get to these questions are a good indicator if you are making the choices to reduce the likelihood of having a cesarean the first time.  To reduce your chances of having a cesarean with your first birth:
-  Know your care provider’s cesarean rate
-  Know your care provider’s VBAC rate
-  Know the same information for the person who does back-up for your care provider – if they don’t match, keep looking!
-  Know the cesarean rate at your birthplace
-  Know the VBAC rate at your birthplace
-  What are the conditions under which your care provider recommends a cesarean?
-  How long is “too long” a trial of labor in their practice?
 
If you already had one cesarean and you decide you want to have a VBAC, here are the recommendations to set yourself up for success:
Surround yourself with people who believe in you and trust your ability to give birth.  If there were anyone with anything negative to say, one mom would ask him or her, “Do you really think that I haven’t looked into this?  And knowing that I have done my research, do you believe that I would do anything that would potentially harm our child?”  If after asking them these questions, the doubter did not back off, she simply told them that the topic was no longer up for discussion because she had done her research and did trust that she was making the right decision for her family.

Find a care provider with a proven track record of supporting VBAC moms. This means knowing their facts and figures, not just the lip service so that you don’t change care providers.

Be okay with changing care providers to get the support you need.  As many moms pointed out, the loyalty usually only goes one way.  We feel attached to our doctors out of a sense of obligation.  For most doctors in a traditional setting, we are just one in a number of patients that they visit with for 15 minutes at a time.  On the other hand, being willing to change means getting the support you and your baby deserve to have a VBAC.

Prepare for a marathon.  Eat well, exercise for strength and stamina, stay healthy and low-risk.  Dedicate your pregnancy to doing everything you can to make sure you can have all your options available during labor.

Find a good birth team to support you.  Having a prepared coach and an experienced doula were high on the list for the VBAC moms.  The more support mom had, the better she was able to move and manage her labor to avoid the repeat cesarean.

Trust your body.  It is important to realize that your body is not broken and to “process” your cesarean.  For some moms, that meant going to therapy.  Others sought counseling, attended ICAN meetings, or wrote on a blog or in a journal about their experience.  Some of them did all of these things – the point is, find your way of starting the healing process and find a way back to belief that you can trust your body to give birth. 
 
The trust in yourself and the complete support of your coaches and your care providers are a good start down the path towards a VBAC.  It is possible and you can give yourself a fair opportunity with preparation and planning.
 

Link List
Things you can do to avoid an unnecessary cesarean:
http://www.ican-online.org/pregnancy/things-you-can-do-avoid-unnecessary-cesarean
 
Risks associated with cesarean:
http://vbacfacts.com/2010/09/19/the-risks-of-cesarean-section/
 
VBAC or Repeat C-section: what you need to know
http://www.childbirthconnection.org/article.asp?ClickedLink=293&ck=10212&area=27
 
ACOG position on VBAC – your care provider should know this if they belong to ACOG
http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm
 
More information on cesareans and related topics:
http://ican-online.org/ican-white-papers
 
ICAN Facebook page:
http://www.facebook.com/ICANonline?sk=wall
 
 
References
(1)  World Health Organization. Appropriate technology for birth. Lancet 1985; 2: 436-7.
(2)  http://transform.childbirthconnection.org/resources/datacenter/factsandfigures/
(3)  http://medconditions.net/trial-of-labor.html
 
 
Disclaimer:
The material included on this site is for informational purposes only.
It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation. This blog contains information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.

 

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