The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Thursday, April 17, 2008

Random Thought for the Day

I was talking on the phone with my cousin today. She just had her second child by repeat c-section. She had her first by c-section as well. So that got me thinking.

As my loyal readers know, I had a c-section back in December with my first (and possibly only... the happy amnesia hormones haven't kicked in yet!) kidlet. My indications for section were listed on the OR report as 'left occiput transverse causing arrested second stage". In English, that means that the Bean's head was turned to the side and wedged behind my left hip. I pushed for 3 hours in a variety of interesting positions, but he just wouldn't turn into a birth-able position. My midwife was wonderful, but after 18 hours of labour to have to have a c-section felt frustrating and disappointing.

And then I thought about everyone else I know who has had a baby in the past year. Doing the math in my head, my rough estimate is that about 90% of my friends who had a first baby this year had a section. And only two of those (out of about 15 or so) were scheduled (one was breech, one had pre-existing medical conditions)... the rest were 'failed' attempts at vaginal delivery. All the reasons seemed legitimate-- fetal distress, not dilating past 6 cms, that kind of thing. But the c-section rates in my circles seem abnormally high. So my first thought would be to wonder what is biasing my sample.

My friends are all relatively young (between 25 and 35) although perhaps a little older than biologically ideal for a first-time mom. They are all professional and well-educated, healthy and fit, and all work full-time. But that's where the similarities end. They have a variety of body types (short to tall, tiny to less tiny), have a variety of careers (pilot, teacher, sales, medicine)... none used reproductive technologies to get pregnant. The time it took them to conceive range from "oops, we're pregnant" to nearly a year. None of them were "too posh to push", and all but one had intended to birth vaginally. Every reason they were given certainly sounded more legitimate than "let's move this along so that I can get home".

Is there something fundamentally wrong with us that so few women are able to birth vaginally these days?

I find this odd.


Anonymous Anonymous said...

No, it isn't odd. Go to NETFLIX and order the Business of Being Born. Yes, I am a Canadian too, and yes, it is based in the United States. BUT! it applies to us too!
I was in a town in AB where the c/s rate was 80%. And yes, I called them on it. Eight out of ten women can't actually give birth without a scalpel? INSANE!
After you have watched the Business of Being Born, waltz on over to ICAN. You aren't too late to take full advantage of Cesarean Awareness Month. Google it. One out of three women are NOT giving birth via the vagina. That is scary! And the reality is that we aren't always better off for it. Higher rates of nicu stays, longer recoveries for the moms, damage to the babies... yeah, I've seen kids who were 'nicked' by the scalpel. Mothers and babies are dying from this procedure. I can count off six in the last 12 months (that made the news) and one was an elective repeat done in Ontario!!! It is horrific.
I'm sorry to say, but you were also induced. And realistically, inductions lead to lots of other problems, including wedging babies in to tight places when they artificially break your water because... you dared to not progress fast enough for someone else's schedule! I'm sorry Bean got lodged in your hip. I'm sorry that you also got a scar. I have one and am now hoping to get a hysterectomy, as the pain from the adhesions and constant bleeding are wearing me down. Yet another thing I wasn't told about... How much were you warned about when you signed those papers? I got crap all for informed consent. Until I had my miscarrage and they told me I might have a few problems getting pregnant again... thanks for the warning?! Now I'm almost seven years out, one miscarriage that I can be sure of and two children (both homebirths with midwives, like you'd get me in a hospital again!), horrific pain and bleeding out a ridiculous amount of blood every week. I wasn't told about that little complication...
Please do yourself a favour and head over to the International Cesarean Awareness Network.
I think it will make your 'wondering' crystal clear. There is something terribly wrong with what is happening to women. Something needs to be done and soon! I'm fearful for my daughter should she decide to have children... what kind of birthing world will she be exposed to?

10:22 PM

Anonymous Anonymous said...

Less malnutrition = much bigger babies that before...

8:18 AM

Blogger Couz said...

I have to agree with both posters. I have never seen anyone be sectioned simply because they weren't progressing fast enough for the doctor's schedule. Most docs are happy to let women labour as long as there are no signs of fetal distress. And trust me... the Bean was wedged against my hip LONG before I was induced. I was unable to walk because of it for the last two weeks of my pregnancy. And I tried many exercises and positions in the days and weeks before the birth to try to change that, all under the direction of my very competent midwife. Also, I wasn't induced until I was nearly 2 weeks post-dates (and that was using my LATEST due date by early u/s-- by my LMP I was a month overdue). I would much rather risk cesarean (even though the recovery was brutal) than risk something happening to my baby, and the risks go WAY up after 42 weeks gestation.

I am familiar with ICAN and TBOBB (although I haven't seen it yet). But what I'm saying is that NONE of these sections seemed 'soft'... they all seemed medically necessary for a number of different reasons. And while I agree that what constitutes 'medically necessary' to me might not be the same for everyone else, but it seems like the situation is more complicated than just claiming 'politics'.

The malnutrition theory is interesting.

8:34 AM

Blogger Lisa b said...

I managed to have a vaginal delivery at a hospital and under a high risk group thought to perform a lot of c-sections so I agree with you Couz, doctors are not rushing to performs c-sections is labour is going well.
I also had a midwife which I think helped but ultimately my baby was born within five hours of my going into labour.

11:53 AM

Blogger Liana said...

Couz, that's such a great question... and it's something I wonder about too.

I have to say I really bristled at the Business of Being Born. I don't doubt that there are some docs out there who do things for convenience, but I really believe that they're in the minority. Most docs do not treat pregnancy as a disease or try to convince women that they're unable to deliver without help. Most docs are not of the "get them in, get them out as fast as possible so I can make more money" mentality. Most docs I know who do obs do it because they love being a part of the miracle of birth, and because they respect and want to empower women. The town I'm working in right now has a C/S rate of 15%. It would be even lower, except that we are often unable to convince women to have VBACs. That's right, we encourage them to have VBACs (when appropriate) instead of doing a supposedly more doctor-friendly C/S.

BTW, the film seems to imply that the high neonatal death rate in the U.S. is due to the lack of deliveries done by midwives. Actually, the neonatal mortality rate in the U.S. is 5/1000, whereas in New Zealand, where almost 80% of women are delivered by midwives, it is 4/1000 (WHO statistics). Not exactly a compelling relationship. For reference, the neonatal mortality rate in Canada is 4/1000, and I'd say Canada's standard of practice is quite similar to the U.S. (not a whole lot of midwife deliveries). The difference seems to have more to do with poor prenatal care in certain socioeconomic groups, and disparities in access to medical services.

I do wonder sometimes though if the frequent lawsuits in the U.S. make American docs more aggressive when it comes to intervening at the slightest hint of compromise.

I'm not sure that I agree that inductions cause problems. I think that inductions are much more likely to be needed in cases where there are already pre-existing problems. In the case of inductions for post-dates, why hasn't that woman gone into labour by herself by 41+ weeks? Maybe, like Dr. Couz pointed out, baby is wedged into mom's hip from the start... it's not that the induction "makes" it happen, ie it's a correlation, not causation.

Anyway, that has been my experience, limited as it is.

6:28 PM

Anonymous Leah said...

I had the same issues you did w/my first kid, then 18 mo later, I elected to have a repeat. My OB said "I'll do anything you want to do, but IF something goes wrong and you rupture, I have limited time to get that baby out...and the outcomes can be very bad." (Shrugs) "PLUS I still have to staff for your labor like you were going to have a C-sec anyway." So I've had 2 C's. I sometimes wish I hadn't have had the 1st C section and would have remained resolute that I could eventually pushed him out. But after 3 hours of pushing, and 24 hours of labor; I was DONE.

Part of me suspects that N. American's version of childbirth is too clinical and we've come to expect these high intervention births. I also suspect that OB/Gyns have come to practice defensive medicine...and I think they didn't have a choice.

Do I have some regrets? Yeah. But in the end, I got two healthy boys so I'm not complaining.

10:28 PM

Anonymous Anonymous said...

Some of it is probably sample bias. Of the 11 women I know who have given birth in the last two years, 9 of them had their water break before they were in labor. Which is wildly elevated compared to the usual occurrence. I don't think there's anything special about us; I think it's just a fluke.

That said, the incidence of C sections is going way up. I think some of it is larger babies. I live in the US, and I think that malpractice is definitely a factor. If things look marginal and you do a section and there is a bad outcome, you "did everything that could be done" and it was inevitable. If things look marginal and you don't and there is the same (inevitable) bad outcome, the doctor should have intervened to save the poor defenseless baby.

I totally agree with Liana in that in many cases with inductions there was something that necessitated the induction. But at least where I live, there are a *lot* of elective inductions. Not 38 weeks and u/s shows 9 pound baby inductions. I'm 38 weeks and tired of being pregnant so lets get this over with inductions. And a lot of those seem to end in C-sections because mom and/or baby were just not ready. Someone I work with was induced at 38 weeks and for whatever reason (dates not right? who knows?) her baby had respiratory distress and spent 10 days in the NICU. I thought it was really sad because it seemed like it would have been less likely to happen if she'd waited. But who knows what would have happened.

It is really interesting that you were (at least) two weeks post-dates when you were induced - where I live, most docs automatically induce when you hit 40 weeks (even for first time moms who on average deliver later than that). So I suspect that that plays a role in inductions that end in C-sections as well.

I'm due in two weeks with my second child, and my first could very easily have ended in a C-section. I was induced/augmented/whatever at 38+6 weeks after my membranes ruptured when I was in a very early stage of labor. I made slow but steady progress until my daughter was delivered, but it took 24 hours. Especially the first nurse I had had spent a lot of time suggesting that I just have a section because I was going slowly and it was going to take a long time and if it took too long I was going to have a C section anyway, so why not get it over with? I personally draw a distinction between 'it might take too long' and 'we've waited as long as we can and we need to have this baby now.' But I'm not sure every woman in my place would have done so. After the shift change the nurse I had never mentioned a C-section, so I think it was to some extent the luck of the draw.

I don't necessarily think that elective C-sections are all bad either. I have one friend who decided to have one after her first kid had a 99th percentile head and she basically had a crotch C-section with a third degree tear and forceps and vacuum etc. She was in the hospital for a week and then was readmitted after a week at home with a kidney infection. The second time around, the kid's head also measured large and was estimated to be slightly larger than her first child. Given her first experience, she decided to have a C-section for her second. And she recovered much more quickly than she did the first time around, and I think it was the right choice for her.

I think overall we probably need to be more judicious with C-sections than we are, because I think we see them a little to much as the 'safe' in 'better safe than sorry.' But so much of it is shades of grey, and without a crystal ball or a time machine, there's no way to know in any individual case what the best choice will be.

1:26 AM

Blogger Christy said...

I guess I am pretty lucky. Out of about 15 pregnancies over the last couple of years (myself included in one of those 15), only 2 have been c-sections (one was a set of 7 lbs twins who had nestled themselves into a nice horizontal position and the other a 10 pounder who didn't want to come out).

Very interesting subject however!

7:56 PM

Anonymous Kemette said...

Hmm....I too ended up with a c-section for the exact same reason you did (but I think you know that).

I do find it odd, but I wonder if your friends are just a bunch of outliers in a random sample. ;)
Of the 10 or so births amongst friends of mine in the past year, I'm the only c-section.

Intersting observation though!

11:39 AM

Blogger Dr. H. said...

Interesting post.

I'll be interested to see what Dr. J. has to say about this, since he does OB here. I don't do OB here, but I do anesthetics for the sections (hence, am involved in the more complicated OB at times).

Nunavut has the highest birth rate /1000 population in Canada (about 24/1000 population, compared with the rest of canada where's it's about 8 to 13/1000 population). Our section rate is about 5%. That's right, SINGLE DIGIT. There's a whole lot of reasons for this, including the fact that we try to send out high risk OB, and it also has to do with the practice styles of the people doing OB here. We also have a much younger OB population here (perfectly acceptable to have your first baby at around 16/17 here). All these things contribute to the low section rate, as well as other things I haven't mentioned or thought of.

However, a very interesting factor is that the Inuit have only really started living a non-nomadic lifestyle since the 1950's. Thus, Inuit women were having their babies out on the land until then. Therefore, bad pelvis/birth complications = dead mom or dead baby or both. Those who did not do well with vaginal delivery did not pass on their genes.

Now consider all the babies who have been born healthy and intact after c-section - babies who likely wouldn't have done well or survived a vaginal delivery. I'm one of them (overdue breech who failed a trial of vaginal delivery and required a section- that was back when breeches were actually allowed to be delivered vaginally!). I would never suggest that these babies shouldn't be born (I wouldn't be writing this in that case) but truly, we are messing with natural selection. I don't know that we'll get to the point were an overwhelming number of women have an inadequate pelvis for vaginal delivery...but it certainly doesn't help that our babies are getting bigger, as someone else pointed out.

It's absolutely amazing to watch Inuit women deliver- primips with 5 push deliveries, babies with no moulding. I'll never look at OB "down south" the same way after having worked here in the north.

6:52 PM

Blogger Shannon said...

Here's another question to your question: Out of those sections, how many of those women were induced in to labour?

I have no idea if there's a correlation between induction and complications leading to sections but I would be interested in finding out.

12:00 PM

Blogger Couz said...

Valid point, but in light of the risks associated with running too far post-dates I would definitely rather assume the risks associated with induction (assuming a medically necessary one after 41 weeks in someone whose dates are certain, not a social one at 38 weeks for someone tired of being pregnant).

So I guess the next question would be... why aren't women going into labour spontaneously anymore?

3:18 PM

Blogger Doctor S. said...

You bring up an interesting point. Something I've given some thought to is how we've removed natural selection in the birth process. ( Of course, we would never let someone die because they are not 'fit.' But this used to be the case very recently, and still is in much of the world.) This plays a very important part because the ability to give birth to babies is the fulcrum on which our genetic fitness pivots. By performing C-sections on anyone with a delivery problem, we will allow for genetic drift in short order. If other selective factors are more important, in just a few generations you may have a population of women, maybe just white women, who can no longer give birth naturally and survive. Then if our modern society ever collapses, a particular unfit race may die out quickly. You got me going on this thing...

10:09 PM

Anonymous Anonymous said...

At thirty-eight weeks, I had had my symphysis pubis dislocated (and never went back firmly, either)for the previous six weeks. The baby had slipped so low that I was having difficulty urinating due to the pressure. I had sciatica. I could not sit, stand, or lie down comfortably in any position. Those are the major reasons that I looked at my midwife and cried with gratitude when she offered to induce me on the Monday if I didn't go on my own over the weekend.

I had also started things off by throwing up everything I ate for five months.

Afterward I insisted on a tubal ligation. I wanted MY system out of service.

7:40 PM

Blogger Fizzy said...

Hi, found you on MiM :)
It's weird that you should say this about C-sections because almost everyone I know did have a vaginal delivery and I know similar people to yourself (25-30, first babies, etc.). So maybe it's just a sampling error? :) I got lucky with my delivery and after letting my epidural run down, I pushed out my eight pound baby in only 30 min or so. I was kind of worried because I'm a tiny woman to have such a big baby but the nurses were awesome and helped me a lot.

4:31 PM

Blogger Jen said...

Couz, You ask, "why aren't women going into labour spontaneously anymore?" I think, at least in the United States, it's because there are a lot of doctors who induce at 39 - 40 weeks for no other reason than they consider the pregnancy done. I've personally heard this out of the mouth of more than one OB. The reasons for cesareans are less than noble as well: Do you think bodies that are induced or augmented function the same as those that go into labor spontaneously? I personally wonder. And I also wonder about the impact of hospital procedures on the laboring body:

7:35 PM


Post a Comment

<< Home