Thursday, February 26, 2009
Recently she wrote about a supersized patient, a first-time mom, conned into an "elective" primary cesarean at, you guessed it, 38 weeks. We'll leave out a lot of the details to protect the mother, but her story could be so many big moms' stories. I can't tell you how often I've seen stories similar to this one. Especially in supersized moms, who face particularly strong bias in obstetrics.
[For those who don't know it, "supersized" is a term from fat acceptance groups and basically refers to anyone over around 300 lbs. or so. It's not an insult, just a way to distinguish different sizes of fat when it's relevant to a story. Not the best term, IMO, but better than "morbidly obese" or "grotesquely obese" or the equivalents I've seen used in the medical research.]
The Cliff Notes Version of the Story
Mom was supersized (mid-300s) but had a healthy pregnancy. The doctor's reason for the cesarean was that she was "huge," had gained a "huge" amount of weight (about 30 lbs., normal for women of average size but considered excessive in obese women by some), and was going to have a "huge" baby. So he talked her into a planned cesarean.
Like I said, an extremely common story for supersized moms these days.
Of course, as many doctors mistakenly do, he assumed that because of her size, she needed a vertical (up and down, belly-button to pubic bone) incision on her skin. This, despite research that shows that outcomes are better in fat women with a low transverse (side to side, just over the pubic bone) incision.
And he put in a Jackson-Pratt drain, despite recent research showing worse outcomes with drains in "obese" women.
(Ugh. Save me from ignorant OBs who won't believe the research.)
The operative report reads that the procedure was "uneventful and easy" and that the baby was delivered "without complication."
As my friend the nurse says, "No complication for him, no."
As is common with 38-week cesareans, the baby went into respiratory distress and went to the Neonatal Intensive Care Unit (NICU). He'll be there at least a week. That's a week without his mama and proper bonding, a week where he's probably getting mostly formula (making breastfeeding more and more unlikely), and a week full of exposure to all kinds of bacteria common to NICUs. He's also jaundiced now and getting treatment for that.
Mom is "miserable," with a lot of post-op pain, despite a truckload of drugs. My friend says the incision looks "ugly" and was leaking serous fluid in at least two places.....but the doctor was unconcerned. We'll just have to wait and see if she develops an infection or a wound separation or other complication.
But Was It Justified?
Now, the baby did turn out to be big. So often doctors predict big babies for big moms and are totally off; ultrasounds are a very poor way of predicting macrosomia (big babies). But in this case, the predictions were correct. So I'm sure a lot of doctors would say....See, this doctor was right. This was a shoulder dystocia (where the baby gets stuck) waiting to happen.
Yeah, the baby was big.... around 10 lbs. And big babies are at more risk for shoulder dystocia. Yet what they "forget" to tell you is that the majority of big babies are birthed vaginally without shoulder dystocia or injuries of any kind.
Doing major surgery on all babies above 9 lbs in order to potentially avoid injuries for a very few is not a very good risk trade-off.....because the surgery also carries risks and harms. Better would be to train doctors to handle shoulder dystocia better, instead of cutting so many women in a futile effort to avoid lawsuits.
The way the medical community hyperventilates about big babies is overdone. Research is clear that unless the baby is at least 11 lbs or more, a planned cesarean is NOT justified. All the medical reviews on macrosomia have noted this.....yet doctors still continue to cut whenever they have the slightest fear about the possibility of a big baby.
To which I say, feh. I had a big baby, over 10 lbs., and I had her vaginally. My friend the nurse also had a big baby, no problems. We both know MANY women who have had big babies without problems. To enforce a cesarean for all babies over 9 lbs means a LOT of women exposed to the substantial risks of surgery, and research simply doesn't support this tradeoff.
Instead, you treat it like any other risk should be treated. You explain to the mom the possible risks of shoulder dystocia, and also the possible risks (present and future) of cesareans. You tell her about the research reviews, which strongly recommend against early induction or planned cesareans for macrosomia. You review the pros and cons of each choice. You share your concerns and opinions, and then you step back and let the mother make the final decision.
Doctors (and ACOG) like to say they are all about informed consent and respecting women's choices, but the truth is that in childbirth, women are infantilized and given very little choice in anything. Either they are outright told what they "must" do, or they are emotionally manipulated, scared, or even bullied into the choice the doctors want them to make.
This is NOT informed consent and this is NOT respecting women's autonomy to make their own informed choices.
A Rough Way To Start Motherhood
So here's this first-time mom, in a huge amount of pain that the drugs aren't really touching, looking like she might be on her way towards a wound complication, away from her baby most of the time just when she most wants to be with him, up against steep odds for making breastfeeding suceed, and looking at a significant post-op recovery.
So much for the c-section being the easy way out. Frankly, it's the easy way out for the doctor, not so much for the mom.
As my friend said, "This is how she's been introduced to motherhood. She was led to expect a neat, clean, simple procedure that would end with her being handed a perfect baby and having a pain-free recovery. She got none of those. Who's to blame?"
I think we all know.
*p.s. Yeah, a lot of doom and gloom posts lately. I promise I have an uplifting one coming soon, as soon as I have time to put it together! Stay tuned.
Monday, February 23, 2009
But one of the most important points the article made was on the impact the change of ONE little word had on women's access to VBACs.
In their 1999 Guidelines on VBAC, the American College of Obstetricians and Gynecologists (ACOG, the trade union for OBs) changed one key word, suggesting that OBs and anesthesiologists had to be "immediately available" instead of "readily available" during a VBAC labor.
That one-word change completely obliterated VBAC as a choice from basically half the hospitals in the country.
A Change in Guidelines
ACOG used to require that OBs and anesthesiologists be "readily available" (meaning they had to be within a few minutes' drive from the hospital). When they re-wrote the guidelines in 1999, the wording became "immediately available."
This ONE-WORD change in the guidelines was the death knell for VBACs in many communities. It means that OBs and anesthesiologists have to be IN the hospital the whole time a VBAC mother is in labor....."just in case."
Most doctors won't do this, both because they don't like to "labor-sit" and because it crimps their ability to see other patients. And smaller, more rural hospitals simply don' t have the personnel to provide 24/7 coverage like that.
Was this change in guideline based on good solid evidence? No. As ICAN's recent press release about VBAC bans notes:
The ACOG guidelines stipulate that a full surgical team be “immediately available” during a VBAC labor, though the stipulation is a “Level C” recommendation, which means it is based on the organization’s opinion rather than medical evidence.Dr. Marsden Wagner, neonatologist and perinatal epidemiologist, criticized the change in guidelines in this way:
This recommendation, "VBAC should be in institutions equipped to respond to emergencies with physicians immediately available," has no data to support it--no studies showing improvements in maternal mortality or perinatal mortality related to the characteristics of institutions or availability of physicians.A Different Standard for VBACs
"Immediately available" sounds good on paper, but it puts a level of demand on VBACs that no other birth has.
For every other birth, it's fine to have doctors on call but not right there---but VBACs got a different standard when the guidelines were changed. "Immediately available" coverage is now a requirement only for VBAC births.
Why the requirement for 24/7 coverage in VBACs? Because there were some infamous cases of uterine rupture in the 1990s. Doctors practiced unsafely, widely inducing VBACs but not monitoring them closely, and some babies died or were harmed. Some parents sued (and rightly so). As a result, doctors became gun-shy about VBACs.
The problem was really not the VBAC itself, but how the doctors were mismanaging the VBAC, and sometimes also the lack of timely response to emergencies. As a result, ACOG suggested that all of their members be immediately available ON-SITE during a VBAC labor, ostensibly protect the mother and baby from harm, but also to protect themselves in lawsuits from the charge of lack of timely intervention.
ACOG guidelines are only guidelines, not laws, but because they are considered "standard of care" in the community, few hospitals dare to defy them. If a hospital lets doctors be merely "on call" during a VBAC labor and something bad happens, they risk a huge malpractice award to the parents because they permitted the doctors practice outside the "standard of care" from their parent organization.
Thus, the "immediately available" requirement was interpreted as requiring 24/7 surgical and anesthesia coverage; without it, hospitals felt they were vulnerable to lawsuits. Since only the very largest hospitals are able to do 24/7 coverage, VBAC was effectively wiped out for half the country, all from the change of one little word.
The 24/7 Dilemma
It's everyone's ideal to have someone standing by at all times in hospitals, ready to intervene in case of an emergency (and not just in maternity units; car accidents can happen at any time of the day or night too).....but it's simply not practical or workable to have 24/7 coverage in most institutions. On-call coverage is good enough for everything else. Why isn't it good enough for VBACs?
VBACs should not be held to a stricter standard just because they are VBACs. All births have potential risks; VBACs do have the risk of uterine rupture, but while this is serious, so are some of the other very rare complications that can happen during non-VBAC births. To say that it's not safe to do a VBAC without 24/7 coverage means that it's not safe to do ANY births at that hospital.
Remember, there's no proof that 24/7 coverage improves outcomes. Before instituting such restrictive guidelines that potentially impacts the health of women so deeply, it is important to have research showing that such coverage makes a difference, that any improvements from such coverage would balance the women that would be harmed from being forced into thousands of repeat surgeries in the smaller hospitals.
The American Academy of Family Practice Physicians took on this "immediately available" requirement in their 2005 Trial of Labor After Cesarean (TOLAC) guidelines. It is uncommon for major doctor organizations to come out and contradict each other like this; the fact that the AAFP did so is a major reprimand to ACOG. Yet in the four years since the AAFP statement came out, ACOG still has refused to modify its guidelines.
The AAFP stated in its TOLAC guidelines [emphasis mine]:
What this change in guidelines is really about is protecting ACOG members in lawsuits, not improving outcomes in VBACs.
TOLAC should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes....
Current risk management policies across the United States restricting a TOL after a previous cesarean section appear to be based on malpractice concerns rather than on available statistical and scientific evidence...We could find no evidence to support a different level of care for TOLAC patients.
VBAC Is Only For Rich Urban Women
One side effect of the "immediately available" rule is that VBAC has become available only to a select few--those who have excellent insurance coverage and who live in a large urban area near a major regional hospital that can afford 24/7 coverage. (Note: Even there it's not always allowed.)
If you live in a rural area, forget it. If you are on Medicaid, forget it. If you don't have a lot of money, forget it. Chances are, you are not "allowed" to have a VBAC. You are not "allowed" control over your own body or say in your own choices.
Doctors in rural areas excuse this blatant discrimination by telling women they can just go to an urban hospital if they really want a VBAC....but the reality is that this is simply not feasible for most families. Most people in rural areas or small cities simply can't afford to drop everything and move to The Big City for several weeks around a birth, nor do most women want to drive several hours to The Big City while in labor.....especially in uncertain weather seasons like wintertime.
So basically, women from smaller towns and rural areas are, in effect, being forced into repeat cesareans by the "immediately available" rule.
Some smaller hospitals "permit" occasional VBACs....if the mothers pay an additional fee for having an anesthesiologist come baby-sit on site while they labor. In effect, they are making it so that only rich women have the choice for VBAC.
Even in large urban areas, access to VBAC is not guaranteed. A number of hospitals in big cities have stopped doing VBACs because some malpractice insurance companies charge more for doctors doing VBACs.
Other hospitals stopped doing VBACs because they are looking at their profit margins, which increase as cesarean rates go up. More cesareans create more billable services, require less staffing (no hands-on labor support), make it easier to schedule personnel, and fills their hospital beds predictably. Hospitals make more money from banning VBACs and increasing cesarean rates.
The sad fact is that it's not about what's best for moms and babies; it's about what's best for their bottom line.
Even if you live in a large urban area and have a local hospital that does accept VBACs, you are still not home-free. If you are on Medicaid, you don't get a lot of choice in your birth attendant. You have to take whomever accepts Medicaid, and many of those doctors don't "do" VBAC. So even if you have everything else going for you, if your Medicaid-approved doctor doesn't do VBACs (and many do not because they can't afford to sit in the hospital 24/7 with you), you're out of luck.
So now there are distressing and deeply troubling patterns of discrimination starting to emerge. All because ACOG decided to change "readily" to "immediately" in their 1999 guidelines.
Speak Up About It
The point is that ACOG needs to change their guidelines. A lack of 24/7 surgical and anesthesia staffing should not be a requirement to "permit" VBAC. Bottom line, VBAC should not be held to a different standard than all other births.
Doctors and hospitals and elected officials MUST start pressuring ACOG to restore the "readily available" wording to their guidelines. We consumers have been pressuring ACOG for years to change the wording but they could care less about the chilling impact their guidelines have had on women and childbirth choices all over the country. It's all about protecting their members from lawsuits instead.
It's been TEN YEARS since that wording was instituted and they still haven't changed it back. They don't care what we think. They don't care about our needs. They only care about their own narrow self-interest.
Still, we consumers must keep up the pressure and intensify it on doctors, hospitals, and elected officials, for the wording will only change when the big guns start pushing ACOG back.
Outraged yet? Want to take action? Link to the Time article on your blog, or email the story to someone (from the TIME website preferably).
Or read more about the Time author's own bumpy journey to VBAC and give it some link love too. Even at a hospital that "allowed" VBAC and in a practice that was supposedly "VBAC-friendly," she was given the ole "bait and switch" routine and strongly pressured to schedule a repeat cesarean about 2/3 of the way through the pregnancy. (Remember, the outright bans are only the tip of the iceberg.)
Or click on this link for ways to start making your views known to your elected officials; ICAN's made it easy for you. You can do a lot of it by email.
Make some noise before VBACs disappear from the country altogether.
Saturday, February 21, 2009
One of the things that most irritates me is doctors trying to promote the idea that women "don't wan't" VBAC anymore. That's total nonsense. Many MANY women still want VBACs but their hospitals or doctors won't "let" them. Others are scared out of VBACs by distorted scare tactics from doctors who just don't want to do VBACs.
"The decline in VBACs is driven both by patient preference and by provider preference," says Dr. Hyagriv Simhan, medical director of the maternal-fetal-medicine department of Magee-Womens Hospital of the University of Pittsburgh Medical Center.
But while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them. Dr. Stuart Fischbein, an ob-gyn whose Camarillo, Calif., hospital won't allow the procedure, is concerned that women are getting "skewed" information about the risks of a VBAC "that leads them down the path that the doctor or hospital wants them to follow, as opposed to medical information that helps them make the best decision."
According to a nationwide survey by Childbirth Connection, a 91-year-old maternal care advocacy group based in New York City, 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.
ICAN's 2009 survey of U.S. Maternity hospitals found that 28% had an outright ban on VBAC, and another 21% had a "de-facto" ban.....meaning that the hospital had no policy against VBAC but no doctors there would attend one. As noted before, this means that about half of all U.S. hospitals basically do not let women choose VBAC.
But this is only the tip of the iceberg. Even in the hospitals where VBAC is ostensibly "allowed," they are often rare. Doctors either scare women out of them or suddenly find reasons why they "must" schedule a repeat cesarean as they get closer to term.
Doctors scare women out of VBACs by giving them "informed consent" forms that list huge and graphically-detailed risks for VBACs (even though these risks are statistically rare), and a few minor and skimmed-over risks for repeat cesareans (even those these risks are statistically about as common). They are told horror stories by doctors of rare complications, yet not told similar horror stories of similarly common complications with repeat cesareans.
In short, they are not being given fair and balanced informed consent about the benefits and risks of VBACs and repeat cesareans. Are these women really getting true "choice" in deciding about VBACs? Are these women really having truly "elective" cesareans? Hardly.
Other women are told they can "try" for a VBAC but as they get closer and closer to the end of pregnancy, suddenly the doctor comes up with all kinds of rules that they have to meet....the baby has to be under xxx pounds, she has to go into labor before her due date, she has to be well-dilated and the baby "engaged" in her pelvis by 38 weeks, yadda yadda.
Author Henci Goer calls this the "Cinderella VBAC" scenario. (Sure you can go to the ball, dear....you just have to meet this impossible list of tasks and conditions first. And even if you somehow do, we'll still probably pull the rug out from under you at the last minute.)
So even in those hospitals where a doctor "allows" VBACs, many of those women get talked out (or risked out) of them at the last minute. This is yet another tactic in the war on VBACs in this country.....make it look like you support VBAC but pull the old "bait and switch" at the end.
Statistics show that around 70% of women who try for a VBAC end up having one.....but most women are not given a chance to be in that 70%. Either they are outright banned from having the choice, are discouraged out of it with distorted scare tactics, or are subjected to "bait and switch" schemes where they are conveniently pressured into a cesarean at the last moment.
Only about 8% of women with previous cesareans go on to have a VBAC in this country nowadays, down from 28% in 1996.....purely because almost NONE of them are given the choice.....or a realistic chance......to try.
That's how far the VBAC-lash pendulum has swung now.....and the figures for women of size nowadays are even more abysmal.
In the end, this will have major consequences for the long-term health of mothers and babies in this country, as the cesarean rate spirals out of control. As the article noted:
Patients and doctors need to be as aware of the risks of multiple cesareans as they are of those of VBACs....With each repeat cesarean, a mother's risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman's chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta--in which the placenta attaches abnormally to the uterine wall--has increased thirtyfold in the past 30 years. "The problem is only beginning to mushroom," says ACOG's Zelop.
The story is not just that half of all US hospitals do not let women choose VBAC, although that in itself is a pretty darn big story.
The even BIGGER story is that even in those hospitals that "permit" VBAC, very few women are actually getting a realistic chance at one.
The story on women's choices in childbirth is even grimmer than is being presented.
Thursday, February 19, 2009
It's about the difficulty that many women with prior cesareans have in getting a chance to have a Vaginal Birth After Cesarean (VBAC). It's about countless women who are essentially being forced into unnecessary surgery that they don't want or need. As the article says:
Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them.The International Cesarean Awareness Network (ICAN, http://www.ican-online.org/) was a big part of helping this writer research her article. In fact, I helped do the phone survey she talks about in the article:
The International Cesarean Awareness Network (ICAN), a grass-roots group, recently called 2,850 hospitals that have labor and delivery wards and found that 28% of them don't allow VBACs, up from 10% in its previous survey, in 2004. ICAN's latest findings note that another 21% of hospitals have what it calls "de facto bans," i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them.Read that again, folks. 28% of the hospitals with maternity services in the United States have official VBAC bans on their books. Another 21% of hospitals have de facto bans.....no official policy, but doctors basically won't attend VBACs there anyhow.
That means a whopping 49% of hospitals in the U.S. will not let you have a VBAC. Nearly HALF of all hospitals do not "permit" women to choose how they give birth if they have a history of prior cesarean.
In my state, the rate was even higher.....54% of hospitals did not "allow" VBAC. Some states are even worse.
Of course, you can choose to have an elective cesarean section in nearly all these hospitals........but if you have a history of cesarean in your background, you are not "allowed" to choose to have a vaginal birth.
Hello??? Reproductive rights anyone?? Alas, apparently only if it makes life more convenient for the doctors. Where is the outrage about this?
And the sad thing is, VBAC is generally even less accessible for fat women. Even if you can find a hospital that "permits" VBACs, many of them strongly discourage "obese" women from trying a VBAC. Some doctor practices outright ban VBAC for women over a certain weight limit.
So take everything the article says about VBAC access and multiply it for women of size. This is not "just" a birth issue or a reproductive rights issue; this is also a fat-acceptance issue.
*More on this tomorrow.
Saturday, February 14, 2009
I originally saw this on Rixa's Stand and Deliver birth blog, and it was just TOOOOO funny not to pass on. Plus it has a really important message, so I was an immediate fan.
This is for anyone who has ever been hassled, stared at, disapproved of, pressured to leave the room or told to go sit in the bathroom when breastfeeding in public.
I've been fortunate not to have been too hassled when breastfeeding my babies in public, but plenty of women have been asked to leave stores, to cover up, or to completely stop nursing.
This is for them! And for all us nursing moms everywhere, celebrating our willingness to give our babies what they needed, regardless of disapproval or raised eyebrows.
[If you have a little one who has watched Disney's Beauty and the Beast, you'll be able to sing along with this, which is really critical to attain the maximum silliness quotient.]
*Sing to the tune of "Be Our Guest" from Beauty and the Beast
See our breasts, see our breasts-
Everywhere, half-naked chests.
While we nurse,
The prudish curse
And wish we'd button up our vests.
Sorry, folks, look away
If we're too decollete,
but this is what boobs are made for,
Not those Wonderbras you've paid for.
We refuse to go feed
Hunched in bathroom stalls---indeed,
We're appalled that you would make such rude requests.
Would you agree to eat
Upon a toilet seat?
See our breasts, see our breasts, free our breasts!
*Correction: Artwork by Wyspiansky, 1902, titled "Macierzynstow"; image from Wikimedia Commons.
**Originally passed along at:
Thursday, February 12, 2009
A recent press release trumpeted the "new" findings of a Canadian researcher that cesarean scar thickness may predict the risk of uterine rupture in future pregnancies. Press releases stated it might be used to predict who should be encouraged to try for a Vaginal Birth After Cesarean (VBAC, pronounced "vee-back") or who should just schedule a repeat cesarean.
I was asked about this here on my blog, too, so I have prepared a detailed post about the pros and cons of this topic.
A word of warning--this post will be fairly technical and long. If you find that sort of thing boring, please feel free to skip this post. I promise, not all my blogging is like that. But sometimes it's important to get into details, and this is one of those times.
The Cliff Notes Version
In a nutshell, beware scientists with a self-promotion agenda.
Remember, this is the era of "Science By Press Release;" this particular press release coincided with a presentation on the topic at the Society for Maternal-Fetal Medicine's annual meeting in San Diego in January. The study hasn't been peer-reviewed or even published yet. It's a little premature to be drawing conclusions or altering policy from it.
Although the findings are interesting, caution should remain the byword in the use of ultrasound to predict the risk of uterine rupture. There are a number of very legitimate concerns about its accuracy, its utility, and the misuse of results that might occur with its widespread adoption.
Remember the take-away message:
Be cautious about using scar thickness to estimate uterine rupture risk. At this point, it deserves further study, but it should not be used to determine who should (and shouldn't) get a chance at Vaginal Birth After Cesarean.
A Little Background Information
First, a few explanations are in order. Birth professionals who read this blog will understand the terms being tossed around, but others may not. So let's take a moment to do a little explaining.
First, remember that one of the risks after a cesarean is that the scar from the incision may come apart in the next pregnancy (the risk is somewhat higher with labor but exists even without labor). This risk is very small, but potentially very serious. However, there are different degrees of separation that must be differentiated.
Terms for scar separation tend to be very inconsistently used, even by medical professionals, but generally fall into a few categories.
Markedly Thin Lower Uterine Segment
Sometimes the prior cesarean scar gets very thin but doesn't separate. This is usually called a "markedly thin" or "paper thin" lower uterine segment. Occasionally some sources will call it a "window" because they can 'see' the baby's hair or features, like a face pressed up against a nearly opaque window. However, "window" is a very inconsistently used term so other terminology is generally preferable.
It is unclear whether or not a "markedly thin" lower uterine segment (LUS) is risky. Many doctors assume it is a disaster about to happen, but there have been a number of women who have experienced this and still gone on to have a VBAC (with no rupture) later on---so obviously those LUS were stronger than the doctors thought.
On the other hand, in some cases, it might have been something about to happen---the problem is we just don't know for sure. Some thinning of the LUS is normal at the end of pregnancy and during labor; it is unclear whether at some point thinning becomes abnormal, and if so, at what point that happens. It is a matter of some disagreement.
Sometimes the scar actually comes open, like a zipper coming a bit unzipped, but the separation is mild and has very little bleeding. This is a "dehiscence" (although some sources call this a "window;" the inconsistency of that term is why it is best avoided).
One medical definition of dehiscence is:
Any defect in the preexisting cesarean scar with no maternal or fetal compromise
Although potentially serious, a dehiscence generally has a good outcome and is clinically fairly insignicant.
Other times, the scar separation is more significant (a "uterine rupture" or UR) and the woman can have significant bleeding and difficulty recovering. A common medical definition of uterine rupture is:
A defect that involved the entire wall of the uterus, was symptomatic, and required operative intervention
A uterine rupture is always dangerous and needs attention, but many babies and mothers are fine with prompt treatment.
On the other hand, sometimes uterine rupture is truly catastrophic, especially if the placenta pulls away from the uterus during the rupture, depriving the baby of oxygen. The baby can sustain brain damage or even die, and the mother can lose her uterus or die too.
The risk of truly catastrophic uterine rupture is small, but if it happens to you, it's devastating. It is certainly something to be taken very seriously indeed.
Weighing the Risks
Although VBAC has a small but potentially very serious risk of uterine rupture, there are also risks from choosing repeat cesareans, including severe hemorrhage, anesthesia accidents, infection, hysterectomy, serious breathing problems for the baby, and maternal death. Furthermore, in future pregnancies, the risk of the placenta implanting abnormally rises significantly, and this can lead to prematurity, fetal death, maternal hysterectomy, and maternal death.
In many years of birth-related work in person and on the internet, I have known women and babies harmed both by uterine rupture during labor and by repeat cesarean and its complications. Let me assure you, I take both very seriously. I urge readers to have the utmost respect and compassion for all those who have their lives impacted by either.
You can debate the relative safety of VBAC vs. repeat cesareans for a long time, but the bottom line is that there is NO 100% "safe" choice after a cesarean. There is risk with trying for a VBAC, and there is risk from deciding on a repeat cesarean.
Although the risk of a severe complication with either choice is low, if it happens to you, it is overwhelming and devastating.
That's why it's so important to use cesareans only when truly needed.
The Allure of the Crystal Ball
In an ideal world, doctors would be able to figure out ahead of time who is most at risk for uterine rupture so those women could opt for a repeat cesarean, while the others could opt to try to VBAC if they wanted (called a "Trial of Labor" or TOL).
Much of the VBAC research in the last few years has been aimed at trying to determine the most important risk factors for uterine rupture. The problem is that a lot of research on UR is contradictory; there is no "smoking gun" study that shows a clear way to predict or avoid uterine rupture.
Even when a risk factor for UR is found, it's only a risk factor and not a true predictor; the vast majority of women with that risk factor will not experience a rupture even if they labor. If you insist on mandatory ERCS for all women with risk factor "X," the majority of those repeat cesareans will not have been necessary and will expose all those women to the considerable risks of repeat cesareans while preventing only a very few ruptures.
Coming up with a reasonable way to manage risk in women with a prior cesarean is one of the great dilemmas of obstetrics today. Frankly, the best solution is to prevent the first cesarean whenever possible, but with cesarean rates at around 1 in 3 of all childbearing women, this is not happening.
Failing primary prevention, the best course is to offer fully informed consent about risks and benefits of each choice, and then let the woman choose which option to pursue. In the end, the decision should be the woman's.
Measuring Cesarean Scar Thickness - The Bujold Study
Measuring cesarean scar thickness is one way doctors try to predict the risk of uterine rupture and know who would be the "best" candidates for a trial of labor and who might be at more risk.
Bujold's study, done in Quebec, measured scar thickness in 236 women. They found that a cut-off of 2.3 mm helped determine a group more at risk for UR in their study group.
Since the study has not even been published yet, it is difficult to evaluate. Here are some of the details given in the press release:
Bujold's study involved 236 pregnant women who had delivered previously by C-section but who planned a vaginal delivery. They used ultrasound to measure the lower part of the uterus, which correlates with scar thickness from the previous C- section, and then followed the women through their deliveries.
During labor and delivery, three of the women had a complete uterine rupture. In six, the scar reopened. Women who had uterine rupture had a very thin scar, Bujold said.
"We found the cutoff is probably 2.3 millimeters" in terms of scar thickness, he said. The average risk of rupture is about 1 percent, Bujold said, but in the study, "if you had a scar smaller than 2 mm, your risk of rupture [was] about 10 percent."
Please note, it's important to look at the strengths and weaknesses of this particular study....and there are several to look at.
The first problem here is that this study is small; the study group had only 236 women. You need a much larger study group than that to determine the significance of any particular risk factor on such a rare complication.
Second, the study has a somewhat higher-than-usual underlying rupture rate. Whenever a study reports a higher-than-usual complication rate, it's always important to dig deeper. A high UR rate suggests that some other factors may be at work.
A large body of research shows that induction and augmentation (using artificial drugs to start or strengthen labor) significantly increase the risk of rupture. This is particularly true if multiple types of induction drugs are used, or if the mother has never had a prior vaginal birth.
Uterine rupture risk is often quoted as being around 1% in a TOL, but that averages together both induced/augmented labors and spontaneous labors. (In VBAC labors that are spontaneous, rupture rates usually hover around 0.5%, or half of a percent.) In this study, the rate of actual ruptures was 3/236, or about 1.3%. Therefore, in all likelihood, factors like induction and augmentation are strongly at work here too. We don't yet know if they controlled for those factors.
It would be interesting to know the details of the cases of the 3 ruptures and the 6 dehiscences, to find out how many involved induced or augmented labor. In many studies, the majority of ruptures and dehiscences involve artificial strengthening of labor contractions.
The other big variable here was partly addressed by Bujold's presentation; the type of suture repair done. This is another giant controversy in VBAC these days; one-layer vs. two-layer repair of the uterus.
Bujold has done research in the past showing that a one-layer repair of the uterus strongly increased the risk of rupture in later pregnancies. However, other studies have not found similar results. It all depends on the study you look at.
A further variable not accounted for in most one-layer vs. two-layer debates is the TYPE of suture material. Bujold and his team used a different type of suture material than the one-layer studies done in the U.S.; his group's higher rate of rupture may simply have to do with the TYPE of suture material rather than the number of layers used. Alas, there has yet to be a definitive study on this topic that controls adequately for other factors.
In this study (as reported here), Bujold found that the combination of a single-layer repair and a scar thickness less than 2.3 mm strongly increased the chances of uterine rupture (21.8 times the risk). That's a very strong increase of risk, which definitely deserves further study.
But again, other studies on single-layer sutures have not found the same level of risk with single-layer suturing. Would other studies measuring scar thickness in single-layer sutured mothers find a similar increase? We just don't know. In addition, we don't know if the type of suture material, pattern of stitch, and induction/augmentation status were controlled for.
This is far from a definitive study on this topic and should be taken with a large grain of salt. Its results merely call for further study, not changes in hospital policy.
The Problems with Studies Measuring Cesarean Scar Thickness
There are a number of problems with studies that have been done using cesarean scar thickness as a predictor of uterine rupture.
The first major problem with this is the issue of inter-observer variation. The type of measuring done here is fairly subjective, particularly between different observers and different methods. Transvaginal ultrasound seems to be more accurate than abdominal ultrasound, yet often abdominal ultrasound is what's being used. Should a woman's chance at even trying for a VBAC rest on data that can vary significantly depending on who (and what) is doing the measuring?
Where we do draw the line at what is “thick enough?” This is where studies come into play. There are several studies that focus on measuring uterine thickness via ultrasound on women with prior cesareans...but none of them are large enough to make any definitive decisions.
When looking at something like uterine rupture that happens about half of a percent of the time, you need to include thousands of test subjects in order to get an accurate assessment of the frequency of the occurrence. We just don’t have that here.
These are interesting preliminary studies that should be duplicated using thousands of women. If there is a way to accurately predict which scars will rupture, this is important information to have, but there is currently insufficient evidence available.
The largest study on uterine scar thickness is the main original one (Rozenberg et al, Lancet, 1996). It was the largest by far with 642 women, but even that falls considerably short of the thousands needed to have the power to determine the statistical significance of a particular risk factor on a rare occurrence.
Third and most importantly, each study finds a different cut-off spot where the risk for rupture increases and becomes "too much."
The original Rozenberg study from 1996 found that a cut-off of 3.5 mm was most useful in determining when risk went up; the recent Bujold study found that a cut-off of 2.3 was the most useful. That's a pretty fair descrepancy. How do you reconcile the difference?
In one study the cut-off is 3.5 mm, in another it's 2.5, 2.3, 2.0, 1.6, 1.5 or 1.0 mm. There are studies to support each of those cut-offs. Which cut-off do you choose to use?
Here's a list of several scar thickness studies in women with prior cesareans. Which one do you trust in?
Study and Cut-off Where Risk Went Up
Rozenberg, 1996 - 3.5 mm (n=642 women)
Qureshi, 1997 - 2.0 mm (n= 43 women)
Montanari, 1999 - 3.5 mm (n= 61 women)
Asakura, 2000 - 1.6 mm (n=186 women)
Suzuki, 2000 - 2.0 mm (n= 39 women)
Gotoh, 2000 - 2.0 mm (n=348 women)
Sen, 2004 - 2.5 mm (n= 71 women)
Cheung, 2005 - 1.5 mm (n=102 women)
Bujold, 2009 - 2.3 mm (n=236 women)
Other Experts Express Concern
The reason that most doctors are not doing this ultrasound scar measurement routinely already (despite the concept having been around for more than 10 years) is because they recognize the weaknesses of it.
In one 2003 survey, only 16% of Canadian doctors were using ultrasound to predict rupture risks. Doctors know the varying cut-off results means that it's not a very reliable method of determining risk.
These concerns were reflected by other doctors who commented on Bujold's press release.
A Strong Potential for Misuse
Dr. Shoshana Haberman, director of perinatal testing services at Maimonides Medical Center in Brooklyn, N.Y., said she has been doing this measurement on women with previous C-sections for a few years. And while the new study results are interesting, she said, the prediction method is not yet definitive.
"We need more data -- that's the bottom line," Haberman said. "We need more data to decide the cutoff."
The ultrasound measure is also operator-specific, she added, so it could vary from person to person.
In the press release, Bujold states that the study should be used to encourage more women to VBAC, given the known increase in risk with each repeat cesarean.
"There is a growing concern about the increase in cesarean births because there is a body of evidence showing that they are associated with higher rates of maternal and infant complications," said Emmanuel Bujold, M.D., with the Department of Obstetrics & Gynecology, Faculty of Medicine, Universite Laval, Quebec. "There are far fewer complications to the mother and infants as a result of a vaginal birth," he continued, "So it is important to determine when a patient with a history of prior cesarean section can have a vaginal birth safely."
However, although this statement sounds well-intentioned, it is disingenuous. Most of the time, these sorts of cut-offs are being used to DENY women access to VBACs, not encourage them. VBACs are extremely hard to come by these days in many areas; this will only be used as ammunition against them, not encouragement for them.
At best you could make a case for using scar thickness measurements as a way to strongly increase the trial of labor rate for women over some random cut-off, but it simply can't be used as a way to "guarantee" no rupture in a VBAC attempt. Nor does it guarantee a definite rupture in women who labor below the cut-off. There are cases of women rupturing above even the 3.5 mm cut-off, and many cases of women who have not ruptured below the arbitrary cut-offs set in these studies.
Alas, it's just not that simple, and no one has rupture-specific psychic powers. It would be wonderful if this were THE key to avoiding uterine rupture and encouraging more VBACs, but it is not.
There are too many problems yet for doctors to start doing universal ultrasound measurements of cesarean scar thickness and using them to determine who is "allowed" to have a trial of labor and who is "required" to have a repeat cesarean.
You might make a case for using this data to counsel women more closely about their possible risks, as long as you mentioned the strengths and weaknesses of the studies about it, and as long as the ultimate choice was up to the parents. Or it might be used for deciding who needs the most careful monitoring during labor after cesarean.
However, in reality, it's going to be used to DENY women the right to decide for themselves, either by requiring mandatory repeat cesareans in women whose scar thickness falls below an arbitrary cut-off, or by using the data to scare women out of considering a VBAC (without sufficient mention of the weakness of the data).
If a woman falls into a group that might be at increased risk for uterine rupture, the logical thing to do is to counsel those parents about their possibly increased risk from a TOL, as well as the possible current and future risks from repeat cesareans.
At this point, it should NOT be used for denying a woman the right to try to VBAC. Yet you know that's how it's going to be used. In fact, research shows that it HAS been used this way already, despite the many weaknesses of existing research.
Informed consent, yes.......coerced surgery, no.
Before this becomes standard of care, there needs to be a LOT of very large, multi-center, randomized, double-blind studies, using ultrasound measurements from multiple observers, and controlled for other factors like suture type/material, induction/augmention, etc.
Frankly, right now, measuring scar thickness is just another way to prevent or scare women from having a VBAC. The intent behind the investigation may be reasonable, but the pratical usage will not be.
Until there's a lot more study on this topic, it is not an accurate way to assess the risk for potential uterine rupture, and it should not be used to determine who should not be "permitted" to try for a VBAC.
Right now, it's just another data dredge and publicity ploy, rather than a really tested and true way of assessing future risk.
As Gretchen Humphries, advocacy director of the International Cesarean Awareness Network says, "It isn't anywhere close to clinically useful and we all know it'll get misused."
Just remember the take-away message:
Be cautious about using scar thickness to estimate uterine rupture risk. At this point, it deserves further study, but it should not be used to determine who should (and shouldn't) get a chance at Vaginal Birth After Cesarean.
Wednesday, February 11, 2009
Now, there are many wonderful blessings to having children and by far the blessings outweigh the bad parenting moments......but oh, when those bad moments hit, they hit with a vengeance.
I'm sure I'm not alone in feeling that a vomiting child ranks right up there among the worst everyday-kind-of-bad-parenting moments. I mean, it's nothing on the scale of Really Bad Things That Can Happen, but on the day-to-day-o'meter, it's pretty high on the Richter Scale.
Guess what I've been doing this week???
Ah, what psychics you all are.
Yup, a tummy bug has been wending its merry way through our household, which of course means that EVERYONE in the house has been trading it back and forth. Which, when you have four kids, is a lot of vomit.
Started a few nights ago with #3, who first vomited on his bed, then ran down the hall to the bathroom (managed to not throw up in the hall, bless his little heart) and then prompty blew chunks all over the bathroom. And I do mean ALL over the bathroom. And I do mean chunks.
Didn't make it to the toilet. Sorta kinda got to the sink but this was projectile vomiting so it got EVERYWHERE. In the sink, on the countertop, down the front of the bathroom cabinet, down the inside of the bathroom cabinet doors, IN the bathroom cabinets, all over the mirror, all over the floor, on the towels, even some on the walls.
Mr. WellRounded and I spent two hours cleaning up all the vomit. Ugh.
Thank goodness there were two of us so we could each spell the other as we alternately gagged and had to run out for fresh air relief. I don't know how single parents manage. I can not deal with the smell of vomit! At least there was someone there to suffer with me and to give me periodic breaks from it.
The next day #1 was down for the count. Last night, #2 and #4 took their turns on the Vomit Comet. Lovely, just lovely.
Mr. WR got it today....not vomiting but definitely feeling majorly yuck-o. I've had it mildly off and on.....I function fine in the day, by evening I'm nodding off and feeling queasy and headachy......and then I'm fine again. Knock on wood, hopefully that's as far as it will get with me.
Tonight everyone but Mr. WR is showing signs of life again; he'll probably be much better tomorrow as well since he slept most of the day today. I think we are back to a normal school day tomorrow, knock on wood.
I'm just hoping that this little tummy foray doesn't turn into a repeat of the Great Tummy Troubles of 2006. That year, we spent six weeks........SIX WEEKS.....with a really really bad Norovirus, trading it back and forth among us all.
Six weeks of vomiting.
Six weeks of cleaning it all up.
Ugh. I practically broke my carpet shampooer and......well, we just ended up throwing some things away because they were a totally lost cause.
Ah yes, those golden parenting moments that you can look back on and laugh about.....MANY years later.
Sorry, I'm not there yet on either that one....or this one. Maybe someday. Right now I'm just praying that this one is not the Giant Economy Size version.
Everyone send us good tummy thoughts, eh?
p.s. As soon as the Tummy Tirades are history, I have a major post to put up on the site. Keep tuning in!
Wednesday, February 4, 2009
Here's a blog entry from a midwife who is currently in med school to become an OB-GYN, and the attitude towards Vaginal Birth After Cesarean (VBAC) and planned cesareans she has encountered.
Here is a little excerpt:
Women are absolutely bullied into repeat cesareans. When I was training as a midwife at a freestanding birth center, we had women transfer to our care late in pregnancy all the time because their doctors were forcing them into a repeat (or primary!) cesarean without medical indication. In fact, we had one mother who said the doctor told her she had to go see a psychiatrist because she was literally crazy for requesting a trial of labor....
One of the ob/gyns at our school (and our main women’s health professor) told our ob/gyn interest club that he thought that his offering of elective cesarean to his patients was completely ethical...But, in reality, his practice does not simply involve maternal request for cesarean. The two women in my class who were his pregnant patients said that he offered them a non medically indicated cesarean at every single visit.
He even went on to explain at that meeting that he tried to convince his patients by extolling benefits of cesarean section, including “your mom can arrange to be there”. He told us that he preferred it because “twenty minutes, the baby is at the mom’s breast, and I get to go home, instead of waiting for twenty hours of labor.” He disparagingly said, “I am not a labor sitter. I am not a glorified midwife"....
Magnify That For Fat Women
Now take this attitude about "doctor-persuaded cesareans" and multiply it times TEN (at least) and you get the kind of pressure many fat women encounter from their doctors during pregnancy.
Sometimes it's really that egregious and obvious, but often it's more subtle and plays upon the fears they have carefully built up for us about how our weight and size might harm our babies.
"Well, dear, obese women have a higher risk of 'xxxx', so better do an early induction now (before the baby gets too big!...or before your blood pressure goes up!....or before your placenta degrades!). But you know, if we just schedule a cesarean, you don't have to go through all that messy labor pain, you can pick your baby's birthday, your mom can be there for the birth, and you'll have your baby in your arms in half an hour."
Or, "Chances are really high that you'll end with a cesarean anyhow; better and safer to do it in a planned and controlled fashion than as an emergency procedure. If there was a real emergency, it would take too long to get through all that extra adipose tissue and your baby might die. You don't want your baby to die, do you?"
(The last argument is used all the time.....and very successfully I might add.....to convince women of size out of trying for a VBAC and into scheduling a repeat cesarean. I've seen it work many many times.)
This is not to say that 'all doctors are bad.' Of course not. There are many wonderful doctors out there, and of course there are bad midwives out there too. It's not one's title or credential that makes you size-friendly or birth-friendly. BUT there is a set of cultural attitudes and beliefs about interventions that tends to cause more cesareans and complications with doctors than with midwives in general.
Some birth attendants truly mean well when they schedule fat women for early inductions and cesareans, thinking that they are providing the best possible chance at a "safe" birth for them, despite little evidence actually supporting that idea.
The problem is that they rarely question that belief, in research or in practice. It just becomes "standard of care" for obese women, without any careful examing of whether it actually does improve outcome or not.
There is just simply a culturally-warped attitude in favor of birth interventions and "the machine that goes PING!" in medical training these days. Add in the additional bias about the 'dangers of obesity' and it means that fat women are being pushed into inductions and cesareans at RECORD rates today.
Fat women can birth vaginally. But often, they are simply not given a real opportunity to do so.
Monday, February 2, 2009
Jennifer Block, author of Pushed: The Painful Truth About Childbirth and Modern Maternity Care, has an awesome article about "elective" cesareans on her blog, which I will quote from at the end of this blog entry.
It's called, "Can We Please Stop Blaming Women for C-Sections?" Her points reiterate a really hot button for me, the blaming of mothers for everything that's wrong with our modern maternal care system.
The press releases that accompanied release of the New England Journal of Medicine article often implied that the main factor driving 38-week cesareans was maternal request, that women were behind all these irresponsible early cesareans simply for the sake of convenience or because they were tired of being pregnant.
In fact, it is doctors who are usually pushing the 38-week timing. Often, they want to avoid any chance of the woman going into labor before the cesarean because they have an exaggerated sense of risk around labor after prior cesarean (or with a breech baby), or simply because they simply want to be done with this patient that much sooner.
Blaming the Mothers
I can't emphasize how much it infuriates me to see these press releases blaming women for the epidemic of too-early cesareans or the high cesarean rate, but it fits the typical pattern these days.....blaming mothers for all the problems.
High cesarean rate? Well it's because of all the older moms, all the fat moms, all the high-risk moms getting fertility treatments now, blah blah blah.
Of course, the high cesarean rate couldn't possibly be because doctors induce women at SUCH high rates now, could it? Couldn't possibly be because doctors no longer attend vaginal breech births, could it?
Nor could it possibly be influenced by the fact that cesareans make the hospitals so much more money, could it? Or the fact that doctors find "scheduled" births so much more time-efficient for their own needs, could it?
Nope, it's all about blaming the mothers.
High "elective" cesarean rate? Well, if you believe the media and doctors, it's because there are all these irresponsible mothers demanding unnecessary patient-choice cesareans, you see.
But the reality is completely different. That NEJM study, for example, only looked at "elective" cesareans......cesareans planned before labor, simply because the mother had had a previous cesarean. No good medical reason, just the fact of a prior cesarean.
But is that really an "elective" cesarean? Is it really a maternal-choice cesarean?
Sometimes the mom is totally on board and wants another cesarean. That's okay, as long as she understands the risks of multiple repeat cesareans. Often, women don't understand just how many risks that entails, but if she has been given full informed consent and still wants another cesarean, that's her choice.
But often, the mother would really like to have a chance at a vaginal birth again, only to be told (falsely) that Vaginal Birth After Cesarean (VBAC) would be far too risky, that VBACs are "illegal" now (no, they are not!), or that she HAS to have another cesarean because her hospital won't "allow" VBACs anymore.
Alas, more and more hospitals are banning VBACs these days. In some states, half of the hospitals with Labor and Delivery wards do not "permit" women to have a VBAC. That means a whole lot of women are being pushed into cesareans they don't want and DON'T NEED.
What it boils down to is a de facto FORCING of women into surgery. This is a gross violation of human rights and basic reproductive rights. No one should be forced to undergo surgery they don't want or need, and yet hospitals all over the country are, in effect, doing just this.
Childbirth Is A Feminist Issue
This is something we as women should really be getting fired up about....someone ELSE is determining what we can do with our bodies, someone ELSE is taking our bodily autonomy away from us. Childbirth issues are very much on the forefront of the women's rights battlegrounds these days, but alas, not everyone understands this yet.
About a third of all childbearing women today have their children surgically; in some hospitals the c-section rate is 40-50% or even more. Some of these are necessary and life-saving....but many are not.
And once they have that first cesarean on board, about 90% of women now have all their future children surgically too. (It used to be much lower but the VBAC bans have changed that.)
Some women have a repeat cesarean truly voluntarily, and if they choose that knowing all the pros and cons, it's fine.......but a LOT more women are doing it simply because they have no choice.
Either their hospital/doctors won't "let" them birth vaginally anymore (since when do you have to ask permission for the right to use your vagina?), or they have been unreasonably scared or even bullied into it.
Some doctors use completely distorted facts to try and scare women out of a VBAC, or they pretend to go along with a VBAC until the last minute when the old bait-and-switch is pulled ("your baby is too big," or "you have to go into labor by 40 weeks or schedule the cesarean," etc.).
Fat women in particular are being talked into planned cesareans and out of VBACs at record rates. Even practices that do still support VBAC often do so only for women of average size, refusing the choice of a VBAC to "morbidly obese" women. Once again, bodily autonomy and childbirth choices are particularly threatened for fat women.
Women forced into or scared into a repeat cesarean are NOT having "elective" cesareans. The high cesarean rate in this country is not being driven by maternal-request cesareans, and the timing of 38-week planned cesareans is not being driven by women either.
It's not about women "choosing" these procedures (or their timing), it's about women's choices being taken away from them.
As Jennifer Block writes on her blog:
Elective implies freely chosen, life-enhancing. Laser eye surgery is elective. Tattoos are elective. But the vast majority of so-called "elective" cesarean sections are not, and it is inappropriate and disingenuous to call them so in the medical literature....
[I]n spite of the true risk, VBACs are often vehemently discouraged. In fact, many obstetricians now refuse to attend them, and hundreds of hospitals have officially banned them. And malpractice liability fears are a strong motivation to schedule the surgery early, so as to avoid the possibility of labor—and vaginal birth. The fact is that VBAC is inaccessible to most women.
So, if a woman with a scar from a previous cesarean goes to her OB and is recommended to schedule a repeat cesarean—and is told that a vaginal birth would be risky, and that anyway it won't be done by this doctor, this practice, or this hospital—can the surgery possibly be called "elective?"