News roundup, C/S and VBAC style

I came across several notable stories and blog posts this week relating to cesarean sections and VBAC.

First, I want to share a lovely birth story of an obstetrician's unexpected VBA2C. Dr. Poppy Daniels' first four births were all induced. She had a cesarean section, two vaginal births, and then another cesarean section. She had scheduled another cesarean section for this fifth birth, but Mother Nature had other plans. Dr. Daniels went into labor the day of her surgery--her first spontaneous labor ever! She was 9 cm dilated when she arrived at the hospital, and it was an easy choice for her to give birth vaginally. In addition to telling the stories of her five births, Dr. Daniels also explains the obstetrical culture in which she trained:

I trained in downtown Philadelphia where an addicted mom with no prenatal care could deliver on one end of the hall, while a high risk IVFer from the Main Line might be delivering on the other end. Although we worked side by side with midwives, we only became involved if their patients developed complications or needed a C-section. Needless to say, like most OB residents, my experience with normal, low-risk physiological birth was minimal.

She comments that modern maternity care exists in a climate of fear and wonders how many of the obstetrical "problems" are caused by the very actions and interventions thought to make birth safer.

Reflecting back over my journey, I see how much the field of obstetrics has managed to contribute and sometimes outright cause complications, all the while assuming they are just keeping everyone safer. And I see how much fear has overtaken the natural birthing process. I’ve said before that shows like Deliver Me, A Baby Story, and Birth Day should be renamed “Fear Factor” because they play on a woman’s often natural concerns about the birth by portraying the whole process as highly dramatic, with a woman strapped down and hooked up, by a doctor gowned and gloved like an alien visitor and often highlighting very anxious family members. Sure a woman has fear, fear that something is going to happen to her or the baby, fear of pain, fear of failure, that she just won’t be able to “do it.” Add in snarky, cynical nurses and doctors who ridicule anyone who seems to want to be in charge of her birth (after all we’re the experts)…limited labor support or assistance in the form of doulas or labor coaches except in certain areas…restricted mobility, food and drink…and almost endless interventions and you have potential for trouble. We have cultivated an environment that this is normal, and somehow now some women even find value in being “risky.”

Dr. Daniels' mentor was Dr. Lauren Plante, author of the fantastic essay "Mommy, what did you do in the industrial revolution?" (cited in my article Attitudes Towards Home Birth in the USA). I recently found out that Dr. Plante, a maternal-fetal medicine specialist, had two midwife-attended home births.

Next, Kristen at Beautiful Birthing Ideas provided a summary of three articles addressing VBAC--all quite favorably--in the June 2010 issue of Obstetrics & Gynecology, aka "The Green Journal."

Next, The Well-Rounded Mama expresses her frustration with the overblown risks of obesity in childbearing women. In Exaggerating the Risks Again, she discusses and critiques a New York Times article titled "Growing Obesity Increases Perils of Childbearing." Her analysis is excellent and covers many points not relating directly to cesarean section or VBAC. An excerpt from her discussion of cesarean section rates in obese women:

The implication here (and alas, many doctors share this perception) is that cesarean sections in women of size are safer than vaginal birth. Barring major complications, nothing could be further from the truth.

The truth is that cesarean sections are FAR more risky than vaginal birth for all women, and especially so for "obese" women. There is the risk of anesthesia complications, hemorrhage, blood clots, and a very serious risk for infection. Doing surgery on a very fat woman is complicated, and the relative lack of vascularity in adipose tissue means that oxygenation and therefore healing is more difficult.

Yet despite the documented increased risk from cesareans to "obese" women, more and more doctors are doing them pre-emptorily. They have such an exaggerated sense of risk around vaginal birth in women of size that they no longer are willing to let fat women even try.....or will only "let" them try if they induce labor early. And therein lies the answer to much of the high cesarean rate in women of size.

And finally, the topic of obesity and pregnant women surfaced at The Unnecesarean in Do overweight pregnant women need separate high risk hospitals?--something proposed as a "solution" to the "obesity problem" by a physician in the New York Times article. Like The Well-Rounded Mama, the author of this post doubts that separate hospitals for obese pregnant women would do anything but push the cesarean rate higher. Great discussions going on in the comments...be sure to join in!