2008 Cesarean Statistics in PA: Primary Cesarean Rates (4 of 4)

In all the flurry about VBAC access and VBAC bans, sometimes the “primary” cesarean rate can get lost in the shuffle.  I think the primary cesarean rate is the most misunderstood of all the cesarean statistics.  I see the media mis-define it over and over, and even occassionally I see medical professionals misdefine it.

And yet, because a primary cesarean, is, by definition, the first cesarean a woman has, it may be, perhaps, her most important.  Because it is the one that forever labels her as high risk in future pregnancies.  As Joy Szabo and many women like her have found, having a vaginal birth after the cesarean, even having multiple vaginal births in ones history, does not erase the scarlet letter that a woman “earns” when she has that primary cesarean. Continue Reading…

Where can I find information to help decide whether or not to pursue VBAC?

A friend recently asked me to pass along some information to help a friend of hers decide whether or not to pursue VBAC.  This was my answer to her: Continue Reading…

Finding the Right Maternity Care Provider

This past weekend I listened as a woman explained that due to her medical condition (epilepsy), her OB had advised her at her first prenatal visit that she could terminate her pregnancy.  I understood that.  For liability reasons her Dr. HAD to make sure she knew that 90% of babies born to mothers with epilepsy are normal, and if that 1 in 10 risk of having problems is too high for her, she had that option.  Fair enough.

But then I listened in amazement as she went on to say that her Dr. reccommended “termination” again at her 2 month visit (apparently she went to her first visit lickety split!), and her 3 month visit, and her 4 month visit, and her 5 month visit…at which point she finally told the Dr. to quit advising this, that she intended to keep the baby even if the baby had deformities.  BTW…her baby was healthy & normal at birth.

I had to wonder what it takes to get a woman to switch care providers?  I mean really, the guy wants to kill your baby, and you are still trusting him to make life and death medical reccommendations for said baby?  Why, even if you were pro-choice (which this woman isn’t), would you continue on with such a glaring difference of opinions?

Unfortunately in America we seem to have bought into the idea that the most important things about choosing a care provider are if they are on our insurance plan, how close they are to our home, and if we like the waiting room decor.  Okay…I might be exaggerating a bit on the last point…but really…the things we take into account really aren’t often important.

I admit…I’ve been guilty of the same kind of decision making.  In choosing my first OB, I just stuck with the GYN I’d seen for about 4 years prior to pregnancy.  I had chosen the practiced based on reccommendations from friends that they were a “Christian” practice.  Let me tell you, as a committed Christian, I often dread having Christian clients who chose their care provider because they are Christian.  Why?  Because they tend to put the care provider on a higher pedestall than they would a non-Christian provider, and don’t question much of what their care provider says to make sure that it matches up with what they personally desire.

And trust me…there is a LOT of variation in practice philosophy amongst care providers (since, as my father used to say, Dr’s PRACTICE medicine–its not really a science so much as an “ideology” where entrenched beliefs often are contradicted by medical research), even Christian ones.  Just looking at the Christian birth care providers I’m familiar with, there are some that:

• will cut episiotomies without consent, 
• state outright that they do not trust vaginal birth and much prefer planned cesareans, 
• will allow women a lot of lattitude in how a hospital birth is carried out–asking her every step of the way if she wants option A, B, or C and avoiding cesarean whenever possible, 
• will attend homebirths with a woman who has had 2 prior cesareans.

Now at a certain point during my first pregnancy I started realizing that the practice I was using was a philisophical mismatch with me, but I didn’t switch.  Why?  Because I felt too busy perhaps?  All I can say is PLEASE don’t follow my example!  It is only through the grace of God that my inaction did not result in my having a cesarean.  Care provider choice does matter.

I do know that many women don’t switch care providers do so out of a desire to “not offend” their care provider.  I had one client who was driving over an hour to see her care provider, knew she didn’t like the practice, and still didn’t switch for this reason.  But here is the thing…as much as a woman may “love” her care provider…her care provider doesn’t love her!  It’s strictly business, and while care providers do have hearts, and their hearts may be saddened if their clients have tragic things happen, they just CAN’T allow themselves to be emotionally involved…to do so with all they see would be too draining. 

Nicole over at “It’s Your Birth Right!!” has written a great pair of posts (Part 1 and Part 2) on “Choosing Wisely.”  She’s been an L&D nurse, and is now a CNM, and has some great insight.  One of her bottom line suggestions that I think is great is that a woman should interview at least THREE care providers before choosing one.  Wow.  Like I said…I didn’t interview my care provider in my first pregnancy.  And even with my second pregnancy I only interviewed one care provider–the one who had been the on-call Doc when my first was born.  Again…3rd pregnancy, I only interviewed one care provider, although this time I’ll use the excuse that I knew I wanted a homebirth, and to my knowledge, at that time I only had one care provider option for homebirth.  Used her again for my 4th birth.  It wasn’t until my 5th birth that I actually interviewed 4 different care providers (and kind of half-way interviewed a 5th over the phone), and chose one.

And guess what? 

She wasn’t covered by my insurance.  And yet she probably cost me less than either of the “in network” providers I interviewed would have cost considering that I would have had a $300 deductible and 20% co-pay for the in network providers. 

She was the furthest away from my house.  Of course after signing up with her I found out she would do home visits for a small fee, and so my appointments literally took only 30-60 minutes of my time, and ALL of that was face time with the midwife, unlike the 2-ish hours I often spent on appointments during my first pregnancy between driving (just 10 minutes from work!), waiting in the waiting room, having vitals taken by nurse, waiting in the exam room some more…then seeing the OB for 5-10 minutes.  Even when I did drive to her office for two visits, I still only devoted a bit less than 2 hours to the visit, and saw my midwife for 30-ish minutes.

Top 10 Ways to Have An Unnecessary Cesarean

In “honor” of Cesarean Section Awareness month, this post has been making the rounds, with a new “way” being added by each blogger.  I first saw the list in “Faint Star Light” with 7 reasons.  Then “Nursing Birth” joined the party, and finally “Enjoy Birth” jumped on the band wagon.  And now…me.  ;-)  (you should note that each author has put her own spin on the text–so go read them all!)

#10 Only take the hospital sponsored childbirth classes, or no classes at all.  After all, an independent viewpoint isn’t important–you’d accept a Ford dealer telling you that the Ford Windstar is the ONLY option for a family vehicle, and never consider a Honda Oddessy or Toyota Sienna, right?

 

#9 Choose a care provider without research – Some OB’s are cesarean happy.  Some OB’s say they support vaginal birth or VBAC’s but their statistics don’t back it up.  Make sure to ask your care provider about her cesarean rate–if it is over 20%, she ISN’T committed to avoiding cesarean–and that is being generous!  My OB practice in my first pregnancy had a 16% cesarean rate (and they aren’t VBAC friendly, despite “talking the talk”), so I know it is possible for even an OB to have such a rate. 

 

#8  Agree to a labor induction without medical indication. – This is a sure fire way to make a birth more of a challenge.  Ask LOTS of questions.  Or, the variation on this, the “back door induction“…allow yourself to be convinced that you are in labor and in need of “augmentation” when you aren’t really in labor.

 

#7  Go the hospital in the early phases of labor.   Because hey, what helps you to relax and allow your body to “do its thing” more than entering a bright, noisy environment where people you’ve never met before want to touch your most private parts.  Remember…(assuming you conceived naturally)…the environment that was necessary to get the baby *in* is the best one to get the baby *out.*  Including some smooching if you are so moved.

         

#6  Don’t eat or drink during a long labor.   Because you really don’t want to do what I did.  I mean really, eating a breakfast befitting a lumberjack while having contractions 3 minutes apart was just CRAZY.  I didn’t have a crystal ball that told me I wouldn’t eat again for nearly 24 hrs.

         

#5  Get an amniotomy too soon.  Because hey, after having 2 or more vaginal births, it’s fun to have an emergency cesarean for cord prolapse (yes, despite what one of my cousins is being told to scare her into a primary cesarean with her second baby, it is QUITE common for babies to still be “high and floating” until a multipara is in active labor–even my 5th baby, who was a petite 6 lbs 3 oz didn’t “engage” until well into labor).  Scaring all your family half to death is fun!  (Yes, I do know someone who had this happen–and frustratingly enough, the family was singing the praises of the Dr. who broke the water because he knew just what to do to save the baby!)

          

#4  Accept pitocin to induce or stimulate contractions.

          

#3  Request an epidural.  Despite having 5 babies with nary a pain medication on board (okay, I did take one dose of Tylenol with Sophie after my midwife confirmed that I wasn’t making progress), I don’t begrudge women epidurals.  I just think women ought to be aware that being restricted to bed increases your risk of having a posterior baby, which increases your chance of cesarean.  Having an epidural (or Pitocin) also means constant fetal monitoring, which has also been shown to increase the risk of cesarean–without improving fetal outcomes.  And finally, I’ve had clients who needed to change positions in order to birth–two in particular needed to use hands & knees.  If they hadn’t been able to get into that position, they would have either needed a cesarean, or had a very poor fetal outcome (9 lb 11 oz baby with shoulder dystocia–mom flipped to hands & knees and the baby slid right out with no tearing.  Had she been stuck on her back she would have needed a big episiotomy and possibly forceps).

          

#2  Accept hospital staff’s comments on lack of progress without challenge.  Don’t concern yourself with stats that shown that “failure to progress” cesearans are much more likely to be performed at 4 p.m. than 4 a.m.–its not that your care provider is just wanting to get home for dinner. 

          

#1 Just ask – or Failure to Ask Questions! – Sure, some moms ask for cesareans, though despite media reports that make you think it is common, survey research indicates that it is very rare.  It is more likely that moms are told they need a cesarean because of xyz (breech baby, twins, big baby) and they don’t ask questions, get second opinions, etc.