RECAP TIME - How to avoid an Unneccessary C-section!
August
31 ,
2009
Those of you who have been following me this past month of August have now had your fill of my assessment of the reasons why the c-section rate is so high. It is now time for me to finalize and review the whole story with some practical advice. What can you do to avoid an unnecessary c-section?
Obviously, there are many things that are not in your control. You cannot control every event that will occur during your pregnancy or delivery. But the ARE many things that you can control, and here they are:
BE HEALTHY! - This means proper diet, proper exercise, yes exercise, during pregnancy. Walking a half hour a day for five days a week has been shown to reduce your chances of gestational diabetes, and thus your chances of needing a c-0section. Remember, you are not "eating for two" you are eating for one adult and developing fetus. You don’t need to eat twice as much, just twice as HEALTHY. Fruits, vegetables, while grains, protein, it is the basics, nothing fancy here. Avoid diabetes and high blood pressure and excessive weight gain - and your chances of needing a c-section go down.
Find a doctor or midwife that you are comfortable with! - NEVER Trust your health to someone who gets impatient when you ask too many questions! Make sure the answers you receive make sense to you, make sure the health care provider provides you the assurances that you need to know that he/she is out for YOUR best interests. To be sure, you will probably NEVER find someone who agrees with you and all of your ideas, but at least he/she can understand your perspective, and guarantee to you that your wishes are paramount and important.
ASK QUESTIONS during labor and delivery, make sure you understand risks and benefits and PURPOSE of everything people tell you. If you ask in a non-threatening way, because you want to know and not because you are trying to challenge people, then most people appreciate that and respond with respect. If they can't handle that, you're in the wrong place. But remember, that respect and genuine desire to be informed is important, don't come because you have an agenda to prove.
If you follow these three instructions, you are much less likely to end up with surgical intervention that you do not need. I haven't yet decided what I will be writing about next month, so I am open to suggestions. I’ve really enjoyed this month, and base on your responses, it sounds like some of you out there have enjoyed it as well. Let's keep this going, and we can all learn from each other.
The C-section Epidemic Reason # 12 - Birthing positions
August
25 ,
2009
I think this will be my final installment in this series, and i must tell you that it has been quite educational for me, and I hope for you all as well. I could probably come up with more reasons for the c-section epidemic, but I want to move on to a new topic in September. Before I proceed with this final blog post in this series, I must give credit to a great friend that I have made this month, Karen Angstadt of www.intentionalbirth.com. She has a great website, and a great mission, and I learned a lot from her. She was also kind enough to invite me as a guest on her internetblogtalkradio show on September 7th (Labor Day) at 1PM. More specific details about the show will be forthcoming on this blog, and on twitter, so stay tuned for that.
If you tune in to the show, we can have the opportunity to talk together and get to know each other better. Maybe argue a bit, maybe learn a bit, and of course, have a good time.
Today;'s reason # 12, is birthing positions. By this I am referring to the position of the Mom while delivering her baby. The "traditional" hospital position is in a hospital bed, mostly on the back, with legs spread apart. However, there is good reason to believe that this may not be ideal. Many women would rather choose to push in a more upright position, such that would be done in a birthing chair. Other's want to be on their side, and others would like to push while on all fours.
I am not advocating any one particular position over another, but I find it very plausible that in many cases, different positions might help get the baby delivered more comfortably and possibly even prevent the need for operative delivery by c-section. I do not have the data to back it up, but anecdotally, many midwives have told me that they have seen it often, and I personally have allowed my patients to try different positions to help get the baby out, and there are cases where it seems to work.
A real randomized trial of pushing positions might be a good idea, but I would prefer allowing women to push however they feel comfortable.
There are two major objections to different positions, however, and we must acknowledge them. The first problem is that it is often difficult to monitor the baby when the Mom is not on her back. I think that this is an important problem, but usually not insurmountable. With a little bit of creativity, we can often monitor the baby anyway, or maybe in many cases, intermittent monitoring might be an alternative option.
The second objection is that if the Mom requires urgent delivery by an operative vaginal delivery such as vacuum or forceps, that she needs to be in the "traditional" position in order to safely deliver that way. I don;t think this is much of a problem though. That is because she can easily lay down in whatever position is necessary quite quickly without losing much time, should the need ever arise.
Most hospitals probably don't have rule prohibiting other positions, but the culture of the hospital certainly doesn;t encourage experimenting with different positions. I think that if we changed this culture, we may just help a few more women have healthy vaginal deliveries.
If any of you have personal stories about different positions in labor, I would love to hear them.
Next post will summarize the 12 reasons, and give some advice to women on what they can do to reduce their risk of cesarean section.
The C-section epidemic - Reason # 11; Fetal Monitoring?
August
23 ,
2009
We move on today to reason # 11 for the C-setion epidemic. BTW, sorry for the break in posting to this blog for a few days, but I have been quite busy at work. But now I'm back to my usual, Reason # 11 is fetal monitoring. Now this is again a very big topic, but it must be considered in our discussion.
Anyone who has been on labor and delivery in the last 30 or 40 years or so, knows that every laboring patient is hooked up to a "fetal monitor". These machine basically follow the baby's heart rate, and the woman's contraction pattern during labor. We get lots of information from this machine, and at least in theory, they are supposed to help us identify which babies are healthy and which are having problems and may benefit from some sort of intervention.
There is no room here for a lengthy discourse on fetal monitoring and how it is interpreted, but suffice it to say as follows. We know that certain patterns reflect a normal baby or a "reassuring" pattern. When we see these patterns, we are HAPPY. We also know when patterns look very bad, and are very concerning. When we see such patterns, we are very concerned, and we need to intervene, which sometimes, though not always, means a c-section.
However, there is also a HUGE amount of gray area. These are the heart tracing that could be interpreted one way or another, and may or may not mean that there is a problem. And herein lies the problem. How many times do we intervene because of a questionable tracing, even when the baby is fine? Does this outweigh the risk of NOT saving a baby who really needs to delivered urgently by c-section? Do the unnecessary c-sections caused by questionable tracings outweigh the risk of missing a few baby's that may need help? Or maybe we should stop worrying about this and say that for that one baby saved, 100 unnecessary c-sections are worth the price? Where do we draw the lines? This is the BIG question, and I am not taking sides on this one. i just want to know what YOU think!
I am just pointing out a very important cause in the rise in the c-section rate. I think it is undeniable that this monitoring does cause a rise, but it may or may not be a justifiable one.
Reason number 12 is next - alternative birthing positions.
The C-section epidemic, Reason # 10 - Medical interventions in labor
August
17 ,
2009
I now am moving on to reason number 10, and here I am really getting nervous. That's because I’m about to start questioning some of what I do every day, something that we should all probably do much more often. I feel kind of like an IRS tax collector who suddenly realized that maybe he's being too harsh, or a prosecuting attorney who suddenly realized that maybe she shouldn't be so harsh on the alleged criminals.
I say this because I am about to reassess medical interventions in labor, and determine if there may be some important influence that interventions in general on the overall c-section rate.
Now I must tell you that this topic is huge, as there are numerous interventions, and each one really needs to be analyzed on its own. So the focus of this blog post is going to be interventions in general, not on any particular one. But I will single pout some major ones for scrutiny to illustrate my point.
The interventions I will single out are some of the most popular ones; pitocin use, prostaglandin use, pain medications (other than epidurals - which we dealt with in reason # 5. I am going to save fetal monitoring for reason # 11, so hold on to your hats.
Let's start with pitocin. It has many uses in the labor and delivery world, among them are the induction of labor, the augmentation of labor to make contractions stronger or more frequent, to induce contractions to perform a contraction stress test, and to help reduce post partum bleeding. In the proper scenario, the use of pitocin may help facilitate a healthy vaginal delivery, and when used appropriately it is a very useful drug. So don't think I would ever advocate the discontinuation of Pitocin use. That would be a shame.
However, the risks of pitocin are medically well established and well known, and these include risks of tachysystole (contractions that are too strong and too long), risks of fetal distress, and more painful and less tolerable contractions.
So it is entirely plausible, that the improper use and too frequent use of this medicine may possibly be a contributing factor to the increasing c-section rate. However, I must admit that it is very difficult to prove this assertion either right or wrong. However, I would advocate that hospitals use very clear criteria, evidence based, for the use of this medicine and how it is dosed and administered. Furthermore, the indications of its use, risks and benefits of its use, need to be very clearly discussed with the patient before it is started, to make sure women fully understand why their doctor chose to recommend this intervention. Fortunately, many hospitals are moving in this direction, and I applaud these efforts, but there is still much work to be done.
Prostaglandins are medications that are designed to “ripen" or soften the cervix, so that an induction of labor has a better chance of success. The most popular of the prostaglandins used for this purpose are dinoprosone (in gel form or in a product called cervidil) and misoprostol.
Since prostaglandins are virtually always used for induction of labor, you should read reason # 2 for more discussion. However, it is also well known that these agents have risks as well, which include concerning fetal heart rate patterns. I will not advocate discontinuing their use, because there are many inductions of labor that are medically necessary where these agents can help a woman have a vaginal delivery. However, I do advocate that care providers need to make sure there are clear guidelines and policies in place to make sure that they are only used when truly medically necessary.
Pain medications are a bit more controversial, because the evidence does not clearly demonstrate an increase in c-sections in woman that have used pain medications. In fact they are generally safe when used properly. However, they can cause a "flattening" of the heart rate, which is medically usually called "decreased variability" and there must have been cases where this less reassuring fetal heart pattern was a contributing factor to the decision to proceed with a c0-section. So these medications need to be used carefully as well.
So my conclusion today is, that care providers need to be careful when they decide to recommend any intervention, and they need to discuss with their patients very clearly why they believe this intervention is important, and what the risks, benefits, and alternatives really are.
Tomorrow’s reason, # 11, will be fetal monitoring.
The C-section epidemic, Reason # 10 - increasing Maternal Age
August
14 ,
2009
We just added an article in our preterm labor section written by Angela Davids of www.KeepEmCookin.com. Check out her site, it is a great resource. Really believe in her cause, so I wanted to plug it in my blog post.
Now lets move on to reason # 10 for the rising c-section rate, advancing maternal age.
It is well known that women in developed countries are delaying childbirth longer and longer. This means that more and more new Moms are in the age range of 35-45 years old, so they have time to develop their loves and careers before they settle down to raise their families. The advantages are obvious to any woman who is trying to develop professionally and independently.
However, the medical consequences of the delay are many. Once the age of 35 passes, fertility and ability to carry a healthy child slowly starts to decrease. Once the age of 490 passes, it starts to decrease dramatically. So more women end up requiring intervention from fertility specialists in order to become pregnant, which increases the rates of multiple births -0 i.e. twins and triplets. This also increases the risk of needing a c-section, as multiple births are more likely to be born by c-section.
Perhaps even more importantly though, even when normal singleton pregnancies are conceived without any medical help, the risks of gestational diabetes, hypertension, and other complications increase with age. Medically complicated pregnancies are much more likely to require medical interventions, including induction of labor and/or cesarean sections. So this further increase the c-section rate as well.
So women having babies at an older age is reason number 10 for the increasing rate of c-sections in our country. Exactly how this can be changed is a different story altogether. I doubt that society can be changed that easily, but for starters, how about more baby friendly and Mom friendly business environment? This way maybe women will be better able to have babies younger without putting their careers at risk.
I am not an expert in this issue (baby friendly workplaces) but some of you reading this blog may be, and I would love to hear what you have to say.
Next reason number 11 - medical interventions in labor.
The C-section epidemic, Reason # 9 increasing birth weights?
August
13 ,
2009
Today I am writing this blog post from a houseboat in Smith Mountain Lake, Virginia, where I am spending a family vacation. AS I am getting a ridiculous amount of exercise hiking, swimming, tubing, and taking care of my kids, and keeping the houseboat in order, it got me thinking about reason # 9.
Since this is a blog, and I love it, I don't have to back up everything I say with references, so you'll have to take my word on a few things, or look it up yourself. It is no secret that diabetes in general, and in pregnancy in particular is on the rise. It is also no secret that birth weights in babies to diabetic mothers tend to be larger than babies in nondiabetic mothers. Furthermore, even in women without diabetes, obesity in general increases birth weights.
The larger the baby, the more likely someone is to have a labor dystocia, which is what happens when the baby does not come out easily, or if the labor doesn’t progress like normal. This in turn makes it more likely that someone will have an assisted vaginal delivery, or a c-section delivery.
So maybe one of the major reasons for the increasing c-section rates has nothing to do with the way doctors and care providers manage the delivery itself? Maybe it's the care provided during pregnancy that matters more, or the care of the woman's health in general? Or more importantly, maybe it is the patient herself and the society she lives in that is the problem?
As obesity rates increase, and diabetes rates therefore increase, so will birth weights, and then so will c-sections! Could it be that better health in general is the answer, and not so much our focus on birth n particular? Just a thought, tell me what you think.
Next reason # 10 - increasing maternal age and medical problems of pregnancy.
Reason # 8 for the c-section epidemic, the decline of the assisted vaginal delivery
August
11 ,
2009
Today I continue my series on the reasons for the current epidemic of c-sections. You may recall that when I discussed reason # 5, the ubiquitous epidural, that I quoted a study that showed that although epidurals don't seem to increase the c-section rate, they do seem to increase the rate of assisted vaginal deliveries. By assisted we mean that the Mom was helped by the doctor to deliver the baby, although the baby was still delivered vaginally. This means that one of two methods were used, vacuum assistance, or forceps.
It so happens that of these two methods, vacuum assistance seems to be the preferred method for most obgyns in the US today, while forceps deliveries are very much in the decline. There are many reasons for this, among them the fact that forceps have a "bad reputation" among patients, and because the rate of maternal lacerations is highervthan with vacuum. As the rate of forceps deliveries declines, the skills are less and less taught, and newer obgyns are less and less comfortable with the technique. To be done safely, it is very important that the physician be well trained in the use of forceps and have the proper skills.
Now I fully understand that the best way to deliver a baby is naturally without any assistance at all. However, there are occasional urgent instances where expedient delivery assistance is medically required. If the doctor cannot assist the Mom to deliver vaginally, then a c-section will inevitably result. In my opinion, the order of preferred approaches to delivery is 1 - natural 2 - assisted vaginal and 3- c-section. For this reason, I lament the fact that the options for assisted vaginal delivery seem to be getting less, while the c-section rate continues to climb.
While I don't think this is a major contributor to the rise in the c-section rate, I still think it is worth mentioning.
Next reason for the c-section epidemic, # 9, are babies getting bigger?
The c-section epidemic Reason # 7 - the decline of the vaginal breech delivery
August
09 ,
2009
Today's reason for the c-section epidemic, is the decline of the vaginal breech delivery. Approximately 3-5% of babies at term happen to be in the breech position, meaning that their butts or feet are facing downward, instead of headfirst like they should be. This presents the Mom and her care provider with a dilemma. If we allow her to labor naturally, the baby will not come out headfirst. This is more difficult on the baby, and many studies have shown that the risk of injury to the baby is significant.
However, it can be argued, that in properly selected cases, such as women that have had large babies before, and a skilled clinician knowledgeable in vaginal breech deliveries, that maybe the risk to the baby is small enough that it outweighs the risk of c-section, and could be an appropriate option.
In order to answer this question, there was a landmark study done called the Term Breech Trial (TBT). The results were published in 2000 in the British Medical Journal the Lancet. This study included centers in numerous countries and thousands of women were enrolled. Without going into the nitty gritty details, the conclusion was that even in well chosen, low risk cases, there was still too much risk involved in trying a vaginal breech delivery, and that women with breech presentation should either have the baby turned with a procedure called an external cephalic version (ECV), or have a c-section.
This study seemed to seal the deal. Now vaginal breech deliveries are basically a thing of the past in most US hospitals. If the ECV fails, or if a woman chooses not to try turning the baby, a c-section is performed.
However, many doctors, and myself included, believe that vaginal breech deliveries should still be considered an option in low risk cases. Let me mention here, that despite the fact that I feel this way, I cannot do this in practice because of hospital practices and group policies that are in place, so I don;t actually offer vaginal breech because my "hands are tied". But that won't stop me from at least voicing my opinion in my own blog!
My reasoning is twofold, and I am not just ignoring the results of a major trial. First of all, I believe that the trial was fundamentally flawed. In fact, in a review of the study by Dr. Glezerman, of the Wolfson Medical Center in Holon Israel, published in the American Journal of Obstetrics and Gynecology January 2006, he pointed out numerous flaws in the study and recommended that the entire study needed to be scrapped. In the abstract he wrote as follows:
"Analysis of the original and new data gives rise to serious concerns as far as study design, methods, and conclusions are concerned. In a substantial number of cases, there was a lack of adherence to the inclusion criteria. There was a large inter-institutional variation of standard of care; inadequate methods of antepartum and intrapartum fetal assessment were used, and a large proportion of women were recruited during active labor. In many instances of planned vaginal delivery, there was no attendance of a clinician with adequate expertise. RESULTS: Most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies. CONCLUSION: The original term breech trial recommendations should be withdrawn."
To make a long story short, I totally agree with his conclusions, and I have yet to hear a decent defense of the TBT in light of his arguments.
Number two, I believe that even if one were to assume that the TBT was totally correct,, and that there truly was increased risk to a vaginal breech delivery, shouldn't that simply be a part of informed consent. Shouldn't we be allowed to simply counsel our Moms and say, "well there is an increased risk, and this is the risk, and these are the risks of c-section, which route would you like to take?"
Why all of the sudden have we taken the decision away from the Mom? In every other area of medicine we give people choices. We tell them risks and benefits. We tell them options. Then WE LET THE PATIENT DECIDE! Why in the world is it different when it comes to breech deliveries? I am baffled to no end by this practice, and it bothers me to the core meaning of why I became a doctor. I didn;t become a doctor to dictate to people what risks are or aren't appropriate. I will advise my patients, and I accept the fact that they may make decisions that I may not agree with, but I can live with the fact that I did my responsibility and provided the best scientific evidence that was relevant to this woman. I rest my case here.
So the decline of the vaginal breech is reason # seven for the increasing c-section rate.
Stay tuned for reason # eight - the decline of assisted vaginal deliveries.
The C-section epidemic Reason # 6 - Patient Demand
August
07 ,
2009
Todays post is about one of the least talked about reasons for the epidemic of c-sections in this country. By discussing this reason, I hope you don;t accuse me of trying to blame the problem on my patients without taking responsibility myself. If you read reasons # 1 through 5, you will see that I scrutinized doctors first, and only then did I turn my magnifying glass onto the patients themselves.
Now here is the big surprise, which would not be a surprise to any obstetricians. Lots of patients WANT c-sections! They ask for it, demand it, and often will do anything to make it happen. The pressure that some women place on doctors to have a c-section can often be overwhelming, and there can be no question that this is a factor as well.
The reasons for this pressure of course can vary from woman to woman. It could be for convenience sake, like one woman who begged me to have a c-section the day before her mother-in-law was going to visit from South Carolina because she wanted to avoid having her baby when her mother-in-law would be there. Or it could be because of fear of labor, or because of fear of lacerations and tearing in her vagina and rectum, or because they believe that it is safer for some reason. All of these and more are reasons why some women pressure their doctors to have a c-section.
The first thing I do when a patient asks me for a c-section is to try to figure out exactly why she is asking. I first need to probe her reasoning. That is because so many women may be basing their request on false assumptions.
For example, one woman asked me to have a c-section because she said it would be safer for her baby. She had heard from friends about how someone's baby died because they "didn't do a c-section when they should have". It took me a while, but after many discussions she learned that there is absolutely NO evidence that babies do better when born by c-section. If anything there is a decreased incidence of certain problems such as TTN (transient tachypnea of the newborn - a breathing problem which is usually minor) with babies born vaginally. Once she was reassured that vaginal deliveries were totally safe for her baby, she stopped asking me to schedule a c-section for her.
So the first thing doctors must do about this problem is investigate the true reasons for the demand, and hopefully counter that with true, evidence based, information.
However, there will still be some patients who are totally informed, and completely educated, and they still want a c-section. "I just don;t want to go through that "labor thing" or "labor is just not for me". Even after extensive and thorough discussions, they are still convinced about what they want. These are kind of awkward situations. On the one hand, who am I to tell her how she should have her baby? After all, it's not me having those contractions and pushing a 7 pound baby out of my bottom! But on the other hand, I've seen so many women who were deathly afraid of labor who rose to challenge like champs and did a super job when it came down to the wire.
These situations are very difficult for an obstetrician, and there are various ways to deal with it, but none of them are good. One way is to simply go ahead and do a c-section. Another way is to simply refuse to do c-sections without a medical indication. A third strategy is to come up with some bogus medical indication (least honest way of course, but it seems to cover your _ss). A fourth is to continue to argue with her until she either agrees or leaves your practice for another doctor. However, I challenge any one of you to argue with a pregnant woman, go ahead make her day! You will not win, I guarantee it! A fifth possible approach would be to simply refer her to another doctor, but that wouldn't help reduce the c-section rate, assuming that was your goal. If anything, it would encourage the other doctor to do more elective c-sections, because he/she would know that it brings in more business.
Bottom line is, I really don;t have a great strategy for this. In this era of patient choice and patient autonomy, it is very difficult to tell someone what is best for her, if they adamantly disagree with you.
Tomorrow, (or maybe Sunday) Reason # 7 - the decline of the vaginal breech delivery
the c-section epidemic Reason # 5 - the ubiquitous epidural
August
06 ,
2009
Now today we step into scary and uncharted territory, and probably the most controversial topic of all so far. Does epidural anesthesia increase the risk of the c-section? If it does, can we at least in part blame the increasing c-section rate on the fact that so many women today get an epidural for pain relief in labor?
It is impossible to talk about this topic without someone getting upset with what you say, so I must at least give you all a very brief introduction to where I stand on the epidural issue in general. We can then move on to what effect they may or may not have on the c-section rate.
As a physician, and especially as a male obgyn, I am in a unique position which forces me to take an objective view of my patients and what they are experiencing. I cannot offer my patients my personal experiences, for obvious reasons. In fact, even a woman that has been through the experience of childbirth should really be able to understand that her experience ios not necessarily the same as everyone elses. It is therefore very very important for me as a doctor to remember who I am and what my place is in the often tense situation called labor and childbirth. I need to know just how my expertise can be helpful.
I can explain to my patients what is normal and what is not, and I can respect every woman's right to know and understand the options available to her and the medical evidence that demonstrates as clearly as possible what the risks and benefits are of any and every intervention.
I am fully aware that some of my internet readers are sometimes skeptical of the medical evidence and they often claim that there is an inherent bias, or a hidden agenda or whatever. I harbor no such suspicions. Every study and every issue needs to be examined, and it is my job to interpret the literature and explain it to my patients in a way that is useful for them in their unique situation. That is why I get paid to do my job, and anything less would be disrespectful to my patients, and just plain wrong.
So when it comes to epidurals, it is my job to describe the risks and benefits according to current medical science. Now I can get back on topic. Today I was going to talk about the effect that the rising rate of epidural anesthesia may have on the rising c-section rate. We are not talking about the risks and benefits of epidural anesthesia in general; we will leave that topic for another time.
So here is the latest best evidence, and you can do with it what you want. In the most recent and most comprehensive review of this controversial topic, in an article titled "Epidural versus non-epidural or no analgesia in labour" by Doctors Anim-Somuah M, Smyth R; Howell C Published by the Cochrane database Syst Rev. Oct 19, 2005; (4):CD000331 the following is a very basic summary of their findings.
They found that epidural anesthesia did NOT significantly increase the risk of cesarean section, but it did increase slightly the risk of instrumental delivery (meaning a vacuum or forceps assisted delivery). The risk of instrumental delivery was 1.38 times as high for a woman with an epidural over a woman without an epidural.
So, if we are to believe the best evidence available, epidurals do not increase the risk of c-section, but they do increase the chances that the doctor will be doing something to "help" out. I have a feeling that my readers on this blog will have something to say about this one, and I'm looking forward to hearing it all (even the criticsism, so go ahead).
I must admit that this is probably a very minor cause of the increasing c-section rate, but I can't help myself from talking about it anyway. For starters, it seems to be neglected whenever the topic of rising c-sections rates is discussed, and furthermore, there is nothing more exciting in obstetrics then delivering a healthy set of twins - vaginally.
I really can't remember anything more fun than delivering not one, but two babies, especially when they both come out the natural way. I was astounded about 3-4years ago when a colleague of mine got privileges at a new "upscale" hospital in our area. He and I delivered at a community hospital, and we were both advocates of vaginal twin deliveries, whenever possible. Some of his patients really wanted him to start using another hospital, which has a reputation of being a little more "upscale."
So he got privileges there, and soon enough, a patient of his, pregnant with twins went into labor. He was called to the hospital, and went to find his patient. He found her, to his surprise, in a holding area ready to be taken to the OR for delivery as soon as he arrived. Astounded, he asked the nurses attending the patient, "why isn't she in a labor room?" "Oh, we just wanted to help move things along so she would be ready for c-section as soon as you arrived", was the response he received.
They then proceeded to tell him that "no one here delivers twins vaginally, are you really planning on a vaginal delivery?" Sure enough, he did the delivery vaginally, and there were numerous spectators that wanted to see this "unusual" delivery.
It just so happens, that this particular hospital has the highest c-section rate in our area, by a long shot.
Let me tell you, that as long as the first twin is coming down head first, there is no reason why the babies cannot safely be delivered vaginally. Unfortunately, many doctors have stopped doing this, either because they lack the skills, or because of their training, or fear of malpractice, or I have no idea why. All I know is that this is wrong.
If you have twins, and your doctor recommends a c-section, please make sure you understand exactly WHY he/she recommended a c-section. Don't just take it for granted that it is necessary.
The C-section epidemic reason # 3 - less people are choosing to VBAC
August
04 ,
2009
The third important reason for the "epidemic" of c-sections in this country is the decreasing rate of VBAC deliveries. VBAC stands for "vaginal birth after cesarean".
If for whatever reason a woman needed a c-section for her first delivery, she is then stuck with the dilemma of how to deliver her second baby. There are two choices her care provider will discuss with her. She can plan for a vaginal birth, or she can plan for another c-section. The advantages of vaginal birth are many, including decreased surgical risk, decreased infection rate, easier recovery and shorter recovery time, and more. The advantages of a c-section are convenience, and the avoidance of an unplanned emergency c-section. However, the big issue really is, the risk of uterine rupture. Uterine rupture is what happens when the scar on the uterus tears open, most often when it is stressed by labor.
This can be catastrophic, causing rapid blood loss to both the baby and the Mom, and possibly resulting in severe consequences, even occasionally death. The fear of uterine rupture is what drives many women and their care providers to choose a planned c-section. However, a good argument can be made for choosing a vaginal delivery, despite the risk of rupture. First of all, the risk of rupture is small, only about 1 in 300. Furthermore, it has to be weighed against the risks of surgery, longer recovery, and the other advantages of a vaginal delivery. Additionally, planning a c-section doesn't necessarily guarantee that you won't have a c-section anyway, as you could go into labor even before your planned c-section. As you can see, this debate can go on and on, with counter arguments either way.
The bottom line is, that this should be a woman's choice. In my practice, we encourage women who desire to VBAC to go ahead and try. Our success rate is pretty good.
However, many hospitals, and many insurance companies don't encourage VBAC, and some prohibit a planned VBAC outright. This is wrong, and this definitely increases the c-section rate. We should encourage patient choice and informed consent, and maybe help eliminate this as one of the major causes of the increasing rate of c-sections in this country.
The C-section epidemic - reason # 2 induction of labor
August
03 ,
2009
I changed my mind, I told you yesterday that i was going to talk about Pitocin, but instead i am going to talk about the rising rate of induction of labor. Let me remind you that i am discussing the rising rate of c-sections, and my assessment of the many reasons that have been suggested as the cause of this problem.
It is very clear that the c-section rate is rising rapidly in this country, and concurrently, the rate of induction of labor (as opposed to waiting for natural labor to commence on its own) is rising as well. Many feel that this is if not the most important, at least it is one of the most important reasons for the rising rate of c-sections.
One thing is clear, in general, when you induce labor artificially, you increase the risk of c-section. This has been well established. However, it is important to note that this is primarily true with only certain types of induction. It is well established in the obstetric literature, that when a woman has had previous vaginal deliveries, and her cervix is "favorable" meaning that it is already dilated, and effaced (thinned out), that her chance of a successful vaginal delivery is pretty much as good as natural labor, even if she is induced.
However, if a woman has not had vaginal deliveries before, and/or her cervix not not "favorable" then her chances of ending up with a c-section are very high. I myself performed a study of inductions at my hospital, and found the "success rate" meaning the rate of successful vaginal delivery in women of the favorable category to be as high as 97%, with the rate of success in women that were "unfavorable" was as low as 50-60%.
it is also important to differentiate between inductions of labor that are medically necessary (in one of the many possible scenarios where the baby needs to be delivered - such as infection, low fluid, too far past the due due date, baby is not growing etc...), and inductions that are "elective" meaning that they are not medically necessary. However, sometimes this distinction is not as easy to make as you might think. For example, how far past the due date is too far (if it is too far past the due date, the baby is at risk of postmaturity, which can be very dangerous)? Some say one week, some say two. Other examples like this are also not quite so clear.
So why is the rate of induction of labor increasing? the following reasons are given:
patient convenience
doctor convenience
fear of malpractice (which may cause doctors to induce when the medical indication may not be so clear, such as fear of postmaturity)
There is no question that the induction rate has an effect on the c-section rate, and the solution should be obvious. We shouldn't induce patients electively, unless they are "favorable" and therefore have the best chance at a vaginal delivery. The only time a woman who is "unfavorable should be induced is if she has a clear medical indication for it. The issue of patient and doctor "convenience needs to be taken off the table. Anyone who goes into obstetrics is aware of the unpredictable nature of this area of medicine, and any women who is pregnant needs to know that the baby will came when he/she is ready, not when you put it into your calendar.
Tommorrow's reason of they day - decreasing rate of "VBAC's"
I have received so much communication about the rising rate of c-sections, that I decided it was time to attack this subject in my blog. The great thing about blogs is that I am allowed to say my feelings, and I do not need to claim that I am speaking for anyone else other than myself. I will also freely tell you that what I say is based on my experience as an obgyn, and may not represent the opinions of any official organization.
It is no secret that the rates of c-sections has risen in this country to close to over 30%. This means that about one third of all deliveries in this country are by c-section. The big question is why this has happened. Everyone points their finger at someone else, and most people have an agenda to promote. I want to try each day to discuss another reason, and tell you what I think about that reason. I would love to hear what you think as well, but if you can please restrict your comments to the "reason of the day".
Reason of the day # 1:
Doctor's Fear of Malpractice
It is no secret that the legal climate in today's world of obgyn is quite challenging. It is also a fact that our malpractice premiums are skyrocketing in a time that reimbursements are shrinking as rapid as the economy around us. Many of us know of fellow obgyns who were practically (or actually) driven out of business because of one or two frivolous lawsuits. That is one horrible way to end a career.
So many lawsuits are based on the following, "if only the doctor had done a c-section earlier, than complication xyz would never have happened."
How much does this really influence the rising c-section rate?
Clearly, it is difficult to deny that it has some influence, and many claim that it is the primary reason for the increase. However, I'm not sure just how much can be blamed on this problem.
Let me do some honest introspection. Do I really do more c-sections because of fear of lawsuits? When I look deep inside, my answer to this is kind of mixed. The truth is,...not really. I actually don't think about lawsuits when I determine if a baby is in distress and needs to be delivered by c-section. I actually think about the information I have available to determine the best way to ensure a safe and healthy delivery. Honestly, I really think only about this baby, and if I'm sufficiently worried, and I think that a c-section is the best way to make sure I have a healthy baby,. and if I would make this decision if it were MY wife and MY baby, then I recommend a c-section.
I honestly can't remember a time that I really made a decision based on fear of a lawsuit. I hope I never do that. In truth, if I thought about lawsuits, I'd probably have a nervous breakdown. I'd rather think about my patients.
I have been having this discussing on twitter, (yes, you should check out my tweets, its' been a blast www.twitter.com/askmyobgyn) about midwives and obgyn's and the perceived notion that there is some sort of war between the two groups. Now PLEASE let me make this clear. I am not commenting on the general state of relations between midwives and obgyns in the US. The fact is that I am simply not an expert in the overall atmosphere and general agreements and disagreements between midwives and obgyns. I am only commenting on my OWN experiences and feelings on this topic, and on my own history. This is my way of telling where I stand on this issue, and my chance to explain my own history and how I came to feel the way that i do.
So, don't paint me with whatever brush you use to paint obgyns "in general" and don't try to argue with me about "them" and 'those people". this is me, and if you want to disagree, please go right ahead, but argue with me, not with "all of those obgyn's" etc...
I did my residency training in obgyn at Sinai Hospital of Baltimore from 2000-2004. Naturally, I was a young schnook out of medical school who was basically clueless, and I had no idea what a midwife was at the time. However, one of the nicest people I met, worked with, and learned from, was a midwife who worked for one of the hospital practices there. That was was my first midwife exposure. She remains a friend of mine, and I have always respected her abilities.
After residency, I joined a private practice which included five midwives and several nurse practitioners. We had one of the busiest midwifery practices in the Baltimore area. We worked together in the trenches for more than four years, until I left the practice and joined my current practice for professional reasons. I now only have physicians as partners, but the hospital employs several midwives that I work with on a regular basis. That is my experience.
I believe that most deliveries should be done by midwives, and that properly trained midwives are awesome at what they do. The reason why they should do the majority o deliveries is because that is what they love to do, that is what they are trained to do, and they are generally very good at it.
However, doctors (obgyns) are trained to do lots of things, normal vaginal deliveries, surgery, gynecologic medicine and surgery, and higher risk obstetrics. That is what I like to do, and I (at least I think so) am good at what I do. If only we had this approach, I wonder how much money we would save the health care system. I'm sure that people have made such estimations, but I wonder if they are considering this in congress when they discuss health care reform.
A well trained midwife knows when something is wrong and requires intervention from an MD. I have unfortunately had the experience of handling complications that were ignored by midwives and could have been prevented had a doctor been called when the problem could have been handled. However, I don;t fault "midwives" in general for this problem, I just fault either the training of the particular person involved, or the negligence of the person involved, or maybe just an honest error. Some doctors experience one or two disasters and then assume that all midwives are irresponsible. That is grossly unfair, we all know that everyone can make a mistake, doctors or midwives. We also know that there are doctors who should know better how to care for their patients. A well trained and conscientious professional knows their boundaries and knows when to call for help.
Tell me what you think, I'm curious to hear your comments.
