Getting real about delivering in the USA.
It seems that my December 10th blog about VBACs pissed some readers off. I can't tell you how happy that makes me.
Though some seem to have misinterpreted my tone of voice as being unsupportive of VBACs, let me assure you, nothing could be further from the truth. I'm as frustrated as many of you that VBACs are so difficult to obtain these days.
A Cesarean Section rate well over 30% is outrageous and probably the most powerful change in this trend will happen when more women become pissed off.
A few readers disagreed strongly with this sentence, taken from the blog: "It sounds like Erin did everything in her power to avoid having a cesarean section with her first baby. She wasn't induced until two weeks after her due date, used a cervical ripener, pitocin, rupture of membranes and eventually an epidural. Still, she just didn't dilate and eventually, her baby quit being a good sport with contractions and Erin ended up in the operating room."
Some readers said Erin did everything wrong and that's why she ended up with a c-section. Another said that Erin should have had a home birth to avoid her induction, epidural and operative delivery. Since none of us really know Erin's whole story, it's easy for us to speculate on how she "should" have managed things.
Here's the reality of how obstetrics is practiced in the US and how that translates to Erin having done her part to avoid a cesarean. First of all, let's look at a mighty significant statistic: 99% of all births take place in a hospital or hospital-associated free-standing birth center. Many of those births are attended by certified nurse midwives and family practice doctors both of whom generally have lower cesarean rates than OBs. Their lower rate is partly due to their birth practices and philosophies and partly due to the lower risk status of their patients (patients at high risk for complications are routinely referred to OBs and these patients tend to have more cesareans).
My entire nursing career has been spent in hospital labor and delivery units. I had the opportunity, early on to assist at home births with midwives but instead, chose to work in the hospital. Why? Not necessarily because I think that's the best and only way to delivery a baby but because 1) I wanted to work with a broader spectrum of the population—women from all walks of life and a wide variety of cultures and 2) I'm a working woman supporting a family and hospital nursing provides a more secure living. Those two add up to a long career birthing babies with all kinds of patients and all kinds of practitioners from the most conservative to the most liberal. It's been a very, very rewarding experience.
When women sign up for a delivery with an OB, midwife or family practice doctor (or osteopath or naturopath) there are certain standards that are followed. I don't necessarily think they're all spot on but the reality is, those standards are the rules and though there are lots of variations, they're still the rules. Back to Erin's situation: she was two weeks past her due date. It sounds like she stalled as long as her doctor/midwife felt she could, waiting for labor to start on its own. At two weeks overdue, her doctor/midwife was worried that 1) the placenta would clock out and fail to support the baby and 2) the baby would be too big to get through her pelvis. Hardly anybody goes past two weeks anymore because we know that when a placenta quits working, babies can die. Labor isn't easy on either the placenta or the baby and both need to be in good health. Placentas aren't designed to function indefinitely. Without a functioning placenta, babies don't stand a chance.
When Erin's spontaneous labor didn't happen, she took the first step in having her labor induced: using a cervical ripener. If a woman's cervix isn't ripe for labor, induction has less chance of working. The cervix needs to be soft, effaced (thinning out) and ready to dilate. That's what cervical ripeners do. There are a variety of products on the market but they work similarly—inserted vaginally for a number of hours (or overnight) they get the cervix ready for its big day. Sometimes, that's all that's needed to kick-start labor. Usually, however, it's a precursor to pitocin. Erin evidently didn't go into labor with her cervical ripener and moved on to the next step—pitocin. When her labor still didn't progress, she took another common step—rupture of membranes—to dial up the intensity of her contractions and, hopefully, accelerate contractions.
It sounds like Erin avoided an epidural for quite a while in hopes of remaining mobile. We all know that walking, changing positions, squatting, birthing balls, and baths are all excellent tools for assisting dilation and dealing with pain. Many women can get through labor with no other pain management and it sounds like Erin was aiming to do just that. Sometimes, however, epidurals are tools that help women dilate. Maybe it's because with the pain gone, women can relax and the pelvic musculature can work more effectively to allow the baby to pass into the birth canal and the cervix to dilate. I've seen this happen hundreds (maybe thousands) of times. With my own first labor, I stalled out at 3 centimeters for 25 hours until I finally got an epidural. Five hours later, my daughter was born. When even this didn't work for Erin, and it appeared her baby was in distress, there was only one thing to do—have a cesarean section.
One reader was upset that I didn't provide more options for women seeking VBACs and suggested they go to VBAC-friendly midwives. I think that's a great idea. The problem is, those midwives have to be supported by VBAC-friendly obstetricians. Many are and I hope they get tons of business and are able to turn the tides. In many areas, women don't have a lot of providers or hospitals to choose from. If their doctor or hospital won't do VBACs, what are they to do? Most women aren't comfortable delivering their babies at home. 1% are, 99% aren't. Is it right that some women can't access a VBAC if that's what they want? No, certainly not. I think women should have all kinds of options but this is the reality of where we are today. Our greatest hope is for all you women who are currently pregnant with your first baby to avoid cesarean sections. Those who are pregnant with a second or subsequent baby, put a lot of pressure on your practitioners to allow VBAC. We're in a supply and demand quandary right now. The supply of VBAC supportive providers is low but if the demand for VBAC doesn't increase, nothing's going to change.
I'm not saying that OBs and midwives who aren't supportive of VBACs are the bad guys. They're just following the rules. They're trying to cover their butts. They're trying to keep their malpractice insurance so they can go on to delivery babies safely. VBACs are safe most of the time but when that one uterine scar ruptures, taking mother and baby with it, that's a tragedy beyond all measure. I know a few doctors who've been in that boat and it's changed them forever. It's devastating for everyone when patients die. Fortunately, it rarely happens anymore. The downside is that we're all paying the price for that one bad outcome. And the cesarean section rate continues to rise.
Got a question for Jeanne? E-mail it to firstname.lastname@example.org and it may be answered in a future blog post.
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