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.

Wednesday, February 21, 2007

Evidence 1, Fear 1... It's a Tie!

So way back when, I discussed elective cesarean section as a reasonable birthing alternative. In women who are adequately informed regarding the risks and benefits of both vaginal and cesarean, elective c-section should be perceived as no less valid a choice than home birth, drug-free birth, unassisted home birth, birthing centre birth, or any other option currently available to pregnant women. Then, in a seeming 180, I posted a few months later regarding my interest in being delivered by a midwife in a hospital setting. Again, all of this remains hypothetical since as far as I know, I remain fetus-free. But it never hurts to be prepared.

My personal views on the subject are pretty predictable to anyone who has been reading my blog for awhile-- as long as women are informed regarding the risks and benefits to both mother and baby, they should be allowed to make the decision that is best for them. As I mentioned before, my only problem with this situation are the increased costs to the health care system if one opts for an elective c-section. But for simplicity, I'm going to overlook that little detail for the purposes of this particular discussion.

I am no stranger to obstetrics. I completed one rotation as a medical student in a relatively small academic centre. My next two month block was also spent in an academic centre, although in a much larger city. During my time in family medicine over the past two years, uncomplicated obstetrics has been a big part of my practice-- I have followed many women through from their initial positive pregnancy tests through to their deliveries and beyond. Now that I'm nearing the end of my 8 months of full-time family practice, I'm seeing several women whose babies I delivered coming back with positive pregnancy tests once again. Sharing such an incredible moment in a family's life still feels like such an honour. And as much as I complain about the effect it has on my free time, I still love the fact that my family practice has such a significant obstetrics component.

From my end, though, I'm still torn. I have seen so many of the worst-case-scenarios it seems like a normal vaginal delivery with good outcomes for both mom and baby are the exception to the rule. I am very aware that my perceptions are heavily influenced by my experiences in high risk obstetrics. I had hoped that my experiences in uncomplicated obstetrics through my family practice would help to give me a more balanced viewpoint when it came time to make birthing choices for myself.

I am uncomfortable with uncertainty. Aside from the odd sports injury, I have never experienced pain. And as one of my friends at work put it, I have an 'internal locus of control'-- I think that's a nice way of saying that I'm a control freak. What scares me about giving birth is the unpredictability of it all. I can plan and prepare for a vaginal birth all I want but may still end up with an emergency c-section. Vaginal births are sometimes uncomplicated and beautiful, but other times-- forceps, tearing, incontinence, sexual dysfunction, uterine prolapse... and that's just the maternal outcomes. The number of things that could potentially go wrong with baby is staggering.

I'm not sure when I started to think this way, but I began to view elective c-sections as a way of maintaining some degree of control and predictability over the whole birthing process. Although the concept of entirely elective c-sections hasn't been completely accepted by the medical community (let alone society in general) it's not something I've talked about very much. But there is plenty of evidence to support the idea. Although none of the data is completely undisputed, studies have suggested that elective c-section may reduce the risk of post-partum urinary incontinence, fecal incontinence, uterine prolapse and sexual dysfunction.* And that's just on mom's end. From the baby's side, studies suggest a reduced risk of unexplained stillbirth, chorioamnionitis and cord prolapse. These possible benefits must be weighed with the increased risks, particularly those associated with post-operative complications for mom and increased incidence of breathing difficulties in newborns.

Unfortunately, the decision to opt for primary elective c-section over vaginal delivery isn't so straightforward as just weighing the risks and benefits of each option. If it were so simple, I'd be first in line for for my uncomplicated, low intervention vaginal delivery. But no one can guarantee anybody that their planned vaginal delivery won't evolve into more-- operative vaginal deliveries (meaning a vaginal delivery that is vacuum or forceps-assisted) increase the risk of complications to mom and baby considerably. If an emergency c-section is required, the risks are increased even more. Each of these scenarios carries a greater risk than if an elective c-section had been undertaken initially.

And that's where I'm stuck. I want one of two scenarios-- a low intervention vaginal birth attended by a midwife in the secure environment of the hospital, or a planned, controlled, elective c-section. Ideally, the former plan would be the ideal one. But again, there is no guarantee that plan won't evolve into something more risky. And that's what scares me, because that's the part I have very little control over.

I am a primip, so by definition I have an 'untested' pelvis. I don't know if I'll be able to give birth vaginally, and I won't know until I try. I am healthy, which is in my favour. I am older than ideal, although still a couple of years away from being considered 'advanced maternal age'. My mother gave birth to three children vaginally with no major complications. But it's still that uncertainty that makes me unwilling to completely discount the elective section option.

A month ago I would have said that my plan would have been to have a midwife-assisted delivery in a hospital. And then the Canadian Medical Association Journal published Maternal Mortality and Severe Morbidity Associated with Low Risk Planned Caesarean Delivery Versus Planned Vaginal Delivery at Term. It wasn't a perfect study, but added more information to the information already out there. And now I'm undecided yet again. And around here, midwives book up fast. So if I want to have a midwife-assisted delivery as an option, I'd better make the decision before I even pee on a stick.

Bah. With my luck, mini-Couz will end up breech and the decision will be made for me.

*Interestingly, more recent studies have actually found no difference in urinary incontinence between c-sections and vaginal births. And they've found that method of delivery is not a significant predictor of sexual dysfunction one year after delivery. So even the 'evidence' isn't set in stone.

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Blogger Suzie said...

Where's a crystal ball when you need one, eh? All I can tell you is that I'm someone who went with a midwife, but whose vaginal birth got complicated. After labouring drug-free for 26 hours, the little guy stalled, pooped, and aspirated meconium. I needed oxytocin, was transferred to an OB, and when he was finally born, my son had a 1-minute Apgar of 2. He needed a flock of people to "get him going", and stayed in the NICU for a week. But - I had no lasting complications, and the transfer from midwife to OB went really well (in truth I had both, as the midwife stuck around and technically she was the one who delivered the baby.) After everything we went through, I would not trade my labour experience for an elective c-section. And it's not because of any romantic notions about vaginal births, but I would still have been too nervous about the risks and annoying side-effects of the c-section. I know you're not asking for opinions, but I'll share mine anyway - I think choosing a midwife for a hospital delivery is the way to go. You get great care during the pregnancy, you get an attendant who kind of does double-duty as a doula, and you know you have an OB and an OR real close by if you need them. Good luck figuring it all out!

10:43 PM

Anonymous Tamara said...

Does Mr. Couz have some parental leave he can take? If you do decide to go with a C-section, you'll probably want him (or friends or your parents or whatever) around to help for at least two weeks. There were nights when I had to get up for midnight feedings, but I could not sit myself up on my own because my pain meds had worn off.

I look at it this way: yes, vaginal birth can get complicated, and things don't always go as planned (like Suzie, I was another emergency C-section) - but with an elective section, you know you're going to be recovering from major abdominal surgery for the first six weeks of your child's life. I'd rather take the chance that things could go swimmingly with a vaginal birth and the recovery time would likely be a lot shorter!

I know the unexpected complications of vaginal birth are scary for a control freak (I am one too), and I took a long time to come (more or less) to peace about what happened... but motherhood will beat the control-freak-iness out of you! Going to have to get used to it sometime! ;)

10:55 AM

Anonymous Leah said...

At 24 weeks, I'm trying to figure out how to have this baby. My last birth (13 mo ago) was high intervention that resulted in a C-Sec but I'm not complaining - my son was healthy and I was fine. In the end all I want is a healthy baby. My OB is fine with VBAC or CSec for me. Another CSec would be elective (probably) so I have to wonder if I'm being selfish by not opting to attempt VBAC. It's very enticing to have a PLAN for my son's birth - a date, an epidural, easy (uncomplicated, anyway) elective CSec.

Dr says I already did it the "hard way" = 24h+ hr labor, lousy epidural, 3 hrs pushing, eventual C-sec; so an elective would be easier than that...but easier than a VBAC? I dunno.

I can't help but think that if only I'd held off on an epidural (I got it at Dr's suggestion because I wasn't dilating or contracting well) my son's descent might have been a little better. If I could have held off altogether I might have been able to labor in positions (rather than on my back) to aid when I was pushing. I presented to L&D at 2 cm, GBS+, ruptured, w/lousy contractions...I know that all the interventions were appropriate but it sure was a lousy 26 hours from then on out. The unrelenting Pit and the worn off (and spotty to begin with) epidural was horrific to push through.. I was exhaused, emotional, and in horrible pain by the time I was wheeled into surgery - I remember very little of it and the movie my husband did shows me completely out of it.

I think I'm opting for the elective CSec because I think medically, there's more control over the situation in general. A healthy, rested mama with a term pregnancy for an elective CSec seems to be a safer bet to me. This time I can at least witness his first moments.

I can get over not having an empowering birth experience - what I couldn't live with is a baby compromised because I wanted a VBAC.

As for recovery - it was very rough for 3 days but I still rolled myself out of bed to nurse my baby every 2 hours and was off pain meds within a week. And that was after labor + pushing...I truly felt run over to begin with. For most women I know, a CSec while no fun, wasn't all that bad to recover from...certainly not 6 weeks - 2 maybe.

Maybe I'm just a big wimp, or don't have enough faith in my biological abilities. I went into my first labor convinced I could do it and had, I feel, very realistic ideas. I'd been at births before, I knew what to expect. Yet my labor was complicated - and there's no telling what this next one will be like.

I'm really in a quandry on this. I've seen some wonderful hands-off low intensity/intervention hospital births and then there was mine. I don't know what to do this time.

2:07 PM

Blogger kimchi said...

I feel like I have to chip in here too... I'm a midwife in Ontario, so I obviously have a bias towards less-interventive approaches when possible. I have given birth three times, so I've been on that side of the issue too. I like the idea of midwife+hospital birth, because it allows for OB/physician care if the situation calls for it, and a less-interventive approach if your labour/birth leans that way. Having been a serious control freak myself (three kids later I think that's waning now...), I can sort of see the appeal of an elective C/S just to have some control over a pretty unpredictable part of life. But it's not going to help with all the other stuff that's unpredictable and uncontrollable in life-with-kids...
And to be a counterpoint to the gals who commented before me, I had the luck to have three normal, uncomplicated, and (I'm embarrassed to say this after reading your stories, Suzie and Leah!) _very_ fast (like 3-1/4 hrs, 1 hr, and _gasp_ 35 min) births... I never would have expected precipitious births, and I'm sure not complaining, but I'm just trying to say that sometimes birth can be pretty good too (though I never want to feel that kind of pain again if I don't get a baby at the end of it too).
Good luck with your 'dilemma' -- having kids is the best adventure in the world!


7:13 PM

Blogger JL said...

Babies on the brain, Couz? :o)

I love reading your internal struggles because I have the same ones, only no where near as educated on the subject.

In the end, we have to do what's best for us and our babies.

Maybe those babies be happy and healthy!

7:45 PM

Blogger Lexy said...

My feelings about birth were for the most part completely opposite to yours. I wanted nothing to do with a c-section, and well thanks to my gymnastics superstar of a baby, who turned and ended up breech at 38 weeks, that's what I got.

Now that I have been through a section, and not a vaginal birth, I often wonder what choice I will make next time. I am a prime candidate (according to my OB) for a VBAC, but as I have had a c-section I can also elect to have a scheduled section over a VBAC.

I'm not pregnant and not planning on getting pregnant again anytime soon, but these choices weigh heavily on my mind. Sometimes I think I would choose another section because it wasn't that bad. Recovery was alright, it wasn't as horrible as everyone seems to think it is. I'm also a bit afraid of the unknown. I know what to expect from a c-section, I don't from a vaginal birth. It freaks me out.

I'm glad I have the availability of choices to me, and have time to figure out what I want to do next time, but I'll still probably be trying to figure it out right up until it happens

7:59 PM

Blogger Amy Tuteur, MD said...

Just curious about your take on the CMAJ study.

The authors claim that elective C-section increases the risk of severe morbidity, but all the deaths were in the vaginal delivery group. I can't figure out how they handled those deaths. Did they list the cause of death among the severe morbidities or did they ignore the deaths altogether?

8:03 PM

Blogger Christine said...

I'm in the exact same place as Lexy - except I already have baby #2 cooking in here. I have no idea what I am going to do. Maybe this baby will be breech too and the decision will be made for me...

8:43 PM

Anonymous Anonymous said...

Hi ER Doc,
I am thrilled that you responded to my question! And for the record, even though I am doing a dual NP/ Midwife Program, I have echoed these thoughts myself many, many times. In any event, I'm sure you will make the "right" choice, meaning the one that works best for you, when the time comes. Good luck, and thanks for writing such an interesting and fun blog!

8:46 PM

Blogger Suzie said...

Sorry - I might not have been clear in my comment - I did have a vaginal delivery (but with complications.) So my feelings on having a c-section aren't based on actually having been through one.

11:35 PM

Anonymous Anonymous said...

The CMAJ study was VERY poor and I think few conclusions can be drawn from it.I have delivered more than 500 babies , mostly high risk and about 200 by C/S - the more vaginal deliveries I do (and the more complications I see)the more paranoid I become.Remember one thing , the annotation "Normal Vaginal Delivery" is a retrospective diagnosis!
As much as I know that anecdote does no equate to evidence , I think that to proudly proclaim that one's approach is "non interventionist" stems from a lack of real training and experience.
The end goal of a pregnancy is a healthy baby and mom and NOT a "birth experience".
We should not be casting out science and evidence in favour of better "birth experiences"
When you have pulled a dead infant out of a ruptured uterus , your enthusiasm for VBAC tends to wane..

11:58 PM

Anonymous Anonymous said...

Re:the CMAJ article:

I'm not sure why anonymous felt this was such a poor study?

Since Amy asked about it, there were three perinatal (baby) deaths, all the women in the trial of labour group. One was a VBAC who presented at 41 wks with no fetal heart, meconium-stained liquid (morphologically normal fetus). Second was a VBAC who presented with PROM (premature rupture of membrances) at 37 wks & was induced with oxytocin (not always recommended in VBAC)...went on to 10hrs contractions then fetal distress with deep transverse arrest. At Csection, baby was hard to get out, & delivered with no signs of life, unsuccessful resusitation. Post mortem showed intracranial hemmorhage but no skull fracture. Third was VBAC with gestational diabetes who presented at 37 weeks with meconium aspiration--went on to deliver by Csection for fetal distress & died at day 4 in NICU for meconium aspiration syndrome complicated by sepsis.

There were also two cases of uterine scar dehiscence ("rupture") in the trial of labour group, both babies & moms were completely fine.

That's the bad news.

The good news--and I'll address this to anonymous especially (the second one, the one pulling dead babies out of ruptured uteruses) is that all physicians get extremely slanted views of OB from day one. We are taught that labour & delivery are fraught with emergencies waiting to happen, that women are on the edge at every second and that the only good outcome--as anonymous declares--should be healthy baby and mom, never mind the birth experience.

Now that I've been out for a few years, watched many many patients & friends go through all sorts of deliveries, and had two myself with one more pending, I think this is a total load of crap. Yes, we must be realistic, things go wrong during labour and now we can do much more about it than we used to be able to. Very few babies or moms die in childbirth any more and that is totally thanks to appropriate interventions.

However, there are also a LOT of inappropriate interventions out there and we all know it. In my last labour I was externally monitored for nearly an hour for no reason--I was just lucky that there were no decels picked up during it that made them rush me to section! Many health care providers encourage epidurals, telling women "if you think you're in pain now, it's only going to get worse", blah blah blah. The evidence is clear though that epidural is a medical intervention with a cascade of side effects--sometimes medically appropriate (the stalled & exhausted 6 cm primip, for example) but does not need & should not be first line solely for pain control. It does, however, make being the nurse, resident and physician's lives much easier. Yes, labour pain gets worse, but your body ramps up to it, and most women can totally handle it if they are supported properly. There are plenty of communities out there with no epidurals available and those women do great. Even the SOGC recommends constant, one to one nursing/labour support which is rarely given.

I was also "coached" as I pushed--you totally know what I'm talking about--"1,2,3,4, hold your breath, don't moan, get mad at that baby, push that thing out, it will be over faster!"...there is absolutely no evidence that this is useful in a non-epiduralized woman and good evidence that it is harmful--leading to a lot of the outcomes everyone worries baout like tearing, urinary incont etc (which Couz is right, all of those outcomes are very sketchily blamed on vaginal births, lots of them are more likely due to genetics and pregnancy itself).

Why shouldn't a great birth experience be an outcome goal?! Whether it be vaginal or abdominal delivery, it is such a shame for residents to get the idea that the ONLY good outcome is physical health and not mental. As a family doctor I deal with the fallout of women's deliveries for years later, and believe me, it's not the pain or surgery they dwell on but the feeling that they weren't supported, that the residents and doctors didn't believe in them and that they only wanted to get that baby out as fast as possible.

I had two great vaginal deliveries so far and hope for a third. I had never been in any kind of pain before and am totally not anything athletic, brave or particularly robust in other areas of my life. And, I am incredibly, incredibly proud of what I did those days and relive parts of them almost daily--and I'm not alone, if you ask women these questions honestly they will often say similar things. I think women like me & kimchi are a bit silenced in our society, noone wants to hear about our amazing births and how we totally handled the pain and felt so incredibly empowered. And friends & patients who have had Csections and vacuums and yes even the dreaded forceps (which in the right hands are amazing things, but residents generally aren't taught to use them very well as everyone goes to surgery instead) still report the same things, as long as they have been well supported and treated with respect and all the best, evidence-based medical care throughout.

Sorry so long. Lots to say. Stick to your guns, Couz. Especially if you're planning more than one child, Csections are more risk than they are worth unless you need them.

11:26 AM

Blogger Amy Tuteur, MD said...

Anonymous 11:26,

I think you are talking about a different study than the one I am referring to. The CMAJ study I am talking about is by Liu in this month's issue. It includes 41 maternal deaths; perinatal deaths are not even mentioned in the article.

11:59 AM

Anonymous Tamara said...

Anonymous wrote:
"Whether it be vaginal or abdominal delivery, it is such a shame for residents to get the idea that the ONLY good outcome is physical health and not mental."

WORD. I never got why "healthy mom, healthy baby" meant that my mental state didn't matter.

I wasted a LOT of energy trying to process my miserable birth experience and it still bothers me sometimes. Though I hid it from almost everyone, I experienced a lot of symptoms of post-partum depression and even a few symptoms of post-traumatic stress disorder. I'd be really interested to see whether there is a correlation between "birth experiences" like abdominal delivery (especially emergency cases) or complicated vaginal delivery and mental health issues.

6:46 PM

Blogger dgm said...

Well, I'll throw my two cents in. My first birth I used a midwife with hospital privileges and it was awesome...even though like some others I ended up after 23+ hours of labor with an emergency c. I had no problem processing it or coping with it afterwards because I was just happy to finally get the kid.

My second child was born in a different state, one where all the hospitals my insurance covered said I could not do a VBAC unless an OB was willing to be on site with me from the moment I was admitted into L&D. Guess what? No doctor would commit to that. I ended up using a midwife anyway who gave excellent prenatal care and who was with me before & aft the "elective" surgery. (My midwife didn't have hospital privileges at the hospital my insurance covered, but she visited longer than the OB who performed the surgery.) The short of it is this: midwives are the way to go because I think the care is much more personal and, I think, complete. I never got the sense that I was being rushed through my appts. like I did when I met with the OB.

Finally, if you're a control freak all I can say is this: let it go, man. Having kids will make you or break you. The ride is much smoother if you allow yourself to roll with the punches.

8:09 PM

Blogger Kat said...

You bring up a very interesting point for discussion. Well, here's my point of view.

I gave birth to my daughter 9 months ago. I had an uncomplicated vaginal delivery at 32weeks 6days. Even though the whole process was very painful (I didn't get my epidural until I was 9cm), I would not have traded it for an elective c-section. And here's why. I had abdominal surgery in Sep 2005, and it was hell. Even though the surgery went well and there were no post-op complications, the pain post-op was horrible, more horrible than the pain post-delivery. On this reason alone, I would not wish the soreness and discomfort of surgery on my worst enemy. Keep that in mind if you do end up having the oportunity to decide if you do have an elective c-section. Also, keep in mind that post-delivery (whether you deliver by c-section or vaginally) you are going to have a baby to look after! You will be sore either way, but at least with a vaginal delivery it wont hurt to hold your baby, to breastfeed your baby (if you decide to BF) or to sleep when you have those few precious moments to sleep! Based on my experience I found the soreness from a V delivery more manageable than surgery. That's not to say you aren't in pain, but I think I would have been much more sore if I had a c-section. There are of course pain meds you can take, but I would be a little concerned about taking too much if breastfeeding.

SO, just something else to think about when you're making your decision.

"Having kids will make you or break you. The ride is much smoother if you allow yourself to roll with the punches." Well put DGM. I'm still trying to learn how to roll with the punches!

10:55 AM

Anonymous Momtotwokidos said...

As far as having control over birth, there is nothing more empowering than a vaginal birth. Sure, there will never be any guarentees, but there is nothing more incredible than pushing out your own baby, while at the same time wanting to rip your husband's, well you know what off. :)

And there is nothing that will inhibit a natural, vaginal birth more than fear. If you don't believe that your body can do it, why bother? I've had two easy, uncomplicated births and I'm normally a whimp. I've found that you should never underestimate the power of positive thinking. Take a deep breath, relax, and tell yourself that you can do it!

11:44 PM

Anonymous Anonymous said...

There's an interesting article on the history and perspectives of midwivery in this month's issue of Utne.

Couz (or any other docs here), do you agree with this assertion that Utne made:

that midwives see childbirth as something a woman does, and they're there to facilitate this natural process, while doctors think that childbirth is something that happens to a woman and is to be controlled.

7:38 PM

Blogger Couz said...

Nah. I don't think that is the underlying premise in obs/gyn. Childbirth is a natural thing... I think that where midwifery and obstetrics differ is that obstetrics is primarily concerned with outcome (i.e. do all that is necessary to ensure healthy mom and baby in the end) whereas midwifery is more concerned with the process (i.e. the birth experience).

And momtotwokiddos-- I'm sure it wasn't intended this way, but if I were a woman who had laboured only to end up with an emergency section I'd really resent your implication that it was (at least in part) my 'fault' for not believing that I could do it. Positive thinking doesn't stablilize baby's heart rate or magically cure cephalo-pelvic disproportion. And it is somewhat insulting to suggest that if a woman had a section after an unsuccessful labour it must have been because she didn't 'believe' that she could do it.

9:40 PM

Anonymous momtotwokiddos said...

""And momtotwokiddos-- I'm sure it wasn't intended this way, but if I were a woman who had laboured only to end up with an emergency section I'd really resent your implication that it was (at least in part) my 'fault' for not believing that I could do it. Positive thinking doesn't stablilize baby's heart rate or magically cure cephalo-pelvic disproportion. And it is somewhat insulting to suggest that if a woman had a section after an unsuccessful labour it must have been because she didn't 'believe' that she could do it.""

I can't believe you read all of THAT into my post which was originally just trying to encouage you! I never said that positive thinking is going to prevent all complications, only that it is powerful. If you sit there and worry day and night that you can't do it and everything is going to go wrong, the chances of that you will need interventions are going to go up. Your hormones are going to go awry and you won't be able to relax and let your body open up. Birth is so much more than just getting the baby is an intricate process in which no aspect should be overlooked, including your train of thought.

Seriously, if you are that uptight about the whole thing, go ahead and get your wonderfully 'safe'planned C-section!

3:48 PM

Anonymous Anonymous said...

Don't forget to consider the fact that c-section babies do not get the high quality passive immunity that vaginally birthed babies do. Obviously, they still get some transplacental antibodies, but it's been proven that they get fewer and they don't last as long and that's true for several diseases, possibly even for all of them, they just haven't looked. I think that should be a consideration for anyone considering an elective c-section. Breathing problems aren't the only complication of c-sections, when you consider the possibility that you are leaving your child incompletely protected from several diseases that can be quite severe in infancy. I would think this would be of concern to a doctor, but I understand it's not information that seems to be common knowledge, so perhaps it's something you might want to investigate further before you have a child. Good luck in whatever you decide.

11:24 AM

Blogger Just Janice said...

Dr. Couz -
I'm a primip (27 weeks gestation) who after much thought on this matter would greatly prefer an elective c-section for the birth of my daughter. My sentiments on the matter are largely consistent with your own and centre around the uncertainity of 'normal childbirth' along with a trade-off of risks. Further, I have no deep seated desire to experience a vaginal birth and do not feel as though I'm somehow missing out on the 'birth experience' by wanting a c-section. As a health economist, I've read the statistics and various resources on the relative merits of the available options...and until a risk free teletransportation of the fetus out of the womb becomes available, I'd like to choose an elective primary c-section.

3:41 PM


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