32.3%

of all babies born in the U.S. last year were born by Cesarean section.

• 12th consecutive year that the Cesarean rate has increased
• the total number of births decreased 2% from 2007 to 2008

See that dip when the rates went down a bit?  That was in the 1990’s when the trend was to encourage moms to have a VBAC.  Then policy changed and we are now at the height of an epidemic that doesn’t seem to be slowing down – especially if an entire state can have an average cesarean rate of 40%.

So in light of the craziness that is going on in U.S. hospitals, you can do a few things to increase your chances that your birth isn’t just a 1 in 3 crap shoot of whether or not you end up with major surgery:

10 Ways to Avoid an Unnecessary Cesarean

Avoid Unnecessary Induction

Carefully Choose Your Provider

Have Great Support at Your Birth

Avoid an Unnecesarean

Yesterday, both the Chicago Tribune and the New York Times ramped it up with pieces on issues greatly affecting the health of mothers and babies.

The Trib ran a great piece on the whole issue of VBAC and how it’s actually not as risky as it’s often presented to be and how it should be readily available  option for women.

Health Experts: Most Repeat C-Sections Unnecessary

Then the NYT ran a great article about a Brooklyn Lactation Consultant who provides women with wonderful breastfeeding support and advice.

The Breast Whisperer

Noruishing a Baby

I love her ground rules:                1. Enjoy the baby.   2. Feed the baby.

Sometimes the first few weeks of an infant’s life can be so stressful (ours was with our first) for new parents that rule number 1 can be forgotten.   I love that she sees her job not simply as getting breastmilk into babies, but fostering the relationship between mothers and their babies.

Underlying both of these articles, which appear to be about two very different things, is the issue of adequate support for women and families during the childbearing year.  Giving women the options, the benefits and risks of these options and then letting them decide which they are most comfortable with and then SUPPORTING them through the outcomes gives families a much better start.

Many times the disappointment I hear in women’s voices when they tell their story about breastfeeding or birthing comes not because of a bad outcome, but it comes at the point in the story when they felt most alone and least supported.  Had these same women been truly supported in a decision that they were allowed to make in those moments, instead of a decision they were coerced into, I believe that in the same situations with the same outcomes, these women would be telling their stories in a very different way.

Adequately supporting mothers and families during the birth year is definitely one major reason that drew me to teaching childbirth classes, serving as a doula, and referring women to La Leche League and lactation consultants when needed.  I support whatever decisions families make for themselves – if a woman herself chooses a repeat cesarean or to formula feed knowing all the benefits and risks on both sides, that is her choice.  What kills me is when women are backed into corners and finding themselves headed toward a repeat cesarean or formula feeding mainly becasue they didn’t have good support for the choices.

Some of these situations we cover are  not necessarily dangerous for the mom or baby, they just change the options that are given to the couple.  Being post-date or going past the due date is one of these.  Depending on your caregiver’s policy induction may highly encouraged anywhere from 39 weeks 6 days to 41 weeks 6 days.  That is a BIG difference.  And if both mom and baby are fine, then they have a lot of options including refusing an unnecessary induction at 40 weeks on the dot.

Another option-changer is breech position of the baby.  While there is a movement in Canada to encourage vaginal delivery of breech babies, the recommended route here in the US right now is surgical.  And since many OB’s do not have the proper training or experience with vaginal breech deliver, I am not comfortable advising moms to ask for vaginal breech delivery with inexperienced caregivers.  So, for parents who find out before the onset of labor, there are many things they can do to encourage the baby to turn: lots of positions for mom to try, chiropractic adjustments, acupuncture, etc can be effective at turning many babies.

So when preparing for these discussions tonight, I came across Dr. Onyeije’s presentation on avoiding a Cesarean.  It mirrors so many of the things I try to stress in class, the  most important being finding a caregiver who shares your perspective on birthing.

That one thing can pave the way to avoiding so many difficult situations for a pregnant couple.  If you are wanting a natural childbirth and go to a practice with a high rate of intervention, then you will probably be very discouraged.  If you want every bit of technology used on you and your baby from the first twinge and you are with a more laid back practice, you will be so frustrated when they send you home from the hospital when you are at 3cm and still in early labor. It makes SUCH a difference.  I they to encourage couples that statistically they will not be the exception.  Exceptions are out there, but you can’t expect to be the exception for the particular practice you are using.

So here it is: 

Here is an excerpt from her article and you can plainly see how where you go to give birth can play a huge role in your outcome.

Advocate Good Shepherd Hospital in Barrington—35 percent (1,724 births 601 C-sections)

Advocate Medical Center in Oak Lawn—35 percent (4,233 births 1520 C-sections)

Resurrection Saint Joseph Hospital, Chicago—34 percent (1895 births 647 C-sections)

Advocate Condell Medical Center Libertyville, 30 percent (545 births 165 C-sections)

University of Chicago Medical Center, 29 percent (2,013 births 585 C-sections)

Advocate Illinois Masonic Medical Center, Chicago, 29 percent (2,931 births 866 C-sections)

Northwestern Memorial Hospital, Chicago, 28 percent (11,958 births 3,418 C-sections)

Elmhurst Hospital, 26 percent (1,426 births 374 C-sections)

Evanston Hospital, 26 percent (3,590 births 966 C-sections)

Adventist Hinsdale Hospital, 26 percent (2,252 births 588 C-sections)

Swedish Covenant Hospital, Chicago, 25 percent, (2,464 births 618 C-sections)

West Suburban Hospital, Oak Park, 20 percent (2,175 births 453 C-sections)

University of Illinois Medical Center, Chicago, 14 percent (2,893 births 433 C-sections)

Some notes about the three hospitals with the lowest cesareans:

• UIC is one of the few hospitals in the area that supports vaginal birth after 2 cesareans (VBA2C).  Most hospitals in the area view women who have had multiple cesareans as too risky for vaginal births and schedule them for repeat cesareans.
• West Suburban and Swedish Covenant both have alternative birthing centers on the premises used by midwifery practices that support natural childbirth and evidence based maternity care.  Women birthing in these birth centers aren’t forced to having labors conform to a curve or else face called cesareans for: “Failure to Progress”, “Arrested Labor,” or “Cephalopelvic Disproportion- CPD.”

if your hospital is not listed here, leave a comment and I’ll crunch the numbers and post your hospital’s rate.  Or you can check out the report yourself and leave it in the comments.

2008 Illinois Hospital Profiles

It does make a difference where you choose to give birth.

Pregnant the second time, Jennifer was determined not to repeat her first experience.  Her first order of business was to find a supportive caregiver.  She had two litmus tests for each doctor she interviewed: “Do you support VBAC?” and  “Do you encourage repeat cesarean  for women who haven’t gone into labor by 41 weeks?”  Both of these were deal-breakers for Jennifer.    Coming from a family who has a history of babies being born between 41 and 43 weeks, she was not going to settle for a practice who routinely induced at 41 weeks.  It was imperative that she be given the opportunity to let labor begin on its own.  Committed to putting herself on a different path for this second birth, if she didn’t like the answers to either of those two questions,  she scheduled another interview with yet another doctor.

After several interviews with several practices she finally found an OB who was more than nominally supportive of VBAC and who looked at the big picture before encouraging induction.  Then as she educated herself about the various interventions, she decided that this time around she wanted to avoid an epidural for as long as possible as she was convinced that this had significantly slowed things down last time.

As her due date came and went,  she was sent in every 3-4 days for a biophysical profile.   She made sure to stay very hydrated so that she had the best chance at her amniotic fluid not appearing too low.  She also made sure to eat something before the visits so that her baby would be awake and energetic during the tests.  She stayed calm and did not stress out as 41 weeks passed.  41 weeks 2 days.  . . 41 weeks 4 days. . .

Her due date was just around the corner and still there were few signs that labor would be commencing any time soon.  Stripping the membranes wasn’t an option as she wasn’t dilated enough for the doctor to perform the procedure.   Her OB finally gave her a deadline of 42 weeks 3 days.  If her body hadn’t done something by then, medical interventions were going to be pursued.  The clock was ticking, but Jennifer stayed calm.

Of course Jennifer did not wind up becoming the first eternally pregnant woman.  At about 11pm on the eve of 42 weeks past her due date labor began.   Throughout this labor she and her husband  made many decisions to help make sure she stayed on a path that had the best chance of ending in a vaginal birth.

The first nurse assigned to care for her did not want her out of her bed when hooked up to the fetal monitor.  Jennifer immediately knew this was not a good fit.  She requested a new nurse from the charge nurse and was presently assigned a nurse who was studying midwifery.  Much better!

Later when her blood pressure was showing high readings, she labored on her left side even though this made dealing with the contractions much more difficult.    Jennifer knew that if her blood pressure didn’t come down, she wouldn’t even have the option of dealing with contractions as she would soon be having another surgical birth.   Laboring on her side was super effective at keeping her blood pressure in the normal range.

When the doctor on call (not the same doc who had cared for her during the pregnancy) lectured her on the risks of VBAC while she was in active labor, and later the risks of shoulder dystocia as this baby looked large, Jennifer kept her cool.  She had educated herself on these things before the birth and was more comfortable with VBAC  and birthing a large baby than she was with the risks associated with major abdominal surgery.

Lastly, she changed positions every 4 or 5 contractions while pushing to effectively use gravity and lots of movement to bring her baby down.   It so amazing when  Jennifer finally eased the baby out. Not quite two hours since she had begun, Jennifer pushed out all on her own body’s power, a 9lb 5 oz.  baby boy.  It was so amazing to see.  He slipped right out and was placed right on her chest to hold and cuddle and nurse.

VBAC moms always impress me.  Not only becasue they face the normal challenges of labor and birth (which are significant!) but they have the added challenge of birthing in a system and an environment that is not designed to facilitate VBAC.  It took determination, patience, and  skilled high pressure negotiation (there’s not much more pressure than when your doctor tells you that your baby might die from the decision you are making!) just to get to the moment where she could even have the opportunity to go into labor.     She later told me that the next day a nurse came in and told her that she was the only one of the floor to birth vaginally that night.

Jennifer had learned since her first birth that it was not her body that had failed in her first birth, but the induction. Her body simply wasn’t ready to give birth yet when she went in for the induction and so the labor was more difficult and ended in a surgical delivery.  This time around, Jennifer’s determination to trust in her body and give it the time it needed payed off.

Good things come to those who wait.

1. Her choice of careprovider made ALL the difference.

She was induced 9 days after her due date with her first baby which started her on the road to her first cesarean.  She also comes from a family whose babies like to come at or around 42 weeks.  So she had two questions when interviewing providers: Do you support VBACs? and Do you wait until 42 weeks with VBACs before encouraging induction?  If the answer to either of those was “No,” she went on to interview someone else.

This was an excellent decision because when she got to the hospital in labor 42 weeks to the day, the doctor on call from her practice clearly wasn’t as comfortable with her VBAC as her regular provider.  If she had been with another doctor,  she could have waited until she went into labor on her own, but she surely would have had much more pressure to induce or schedule another cesarean.

2.  She was  VERY informed.

She read and researched a LOT while pregnant and knew the risks of each of the procedures that were common in her situation (induction, augmentation of labor, etc) and had prepared alternative suggestions that she was more comfortable with.  Being informed was so helpful to her in labor when the doctor on call reminded her of the dangers of VBACs including a ruptured utuerus and dead baby.  She was able to remain calm, remind the doctor that the risk of surgical complication was statistically greater than the dangers posed by VBAC, ask for some juice and continue on with her labor.  She was amazing.

3. You have to deal with the birth you are given.

On her birth plan it was clearly written that she wanted as much freedom of movement as possible.  She knew that as a VBAC she would have continuous electronic fetal monitoring and she would be limited in movement by the length of the wires tethering he to the machine.  Not ideal, but not stuck in bed either.  Then her blood pressure remained high.  So she was instructed to lay down in bed on her left side to reduce her BP.  In that moment she had to choose:  be more comfortable by moving around and jeopardize her chance at VBAC completely,  or lay in bed, deal with the increased discomfort of her labor and stay on the path to a VBAC.   She valiantly chose the latter, watched her BP drop significantly  as she labored on one side or the other,  and stayed on that path to pushing out her baby on her own.

It was amazing.

“We have a secret in our culture, and it’s not that birth is painful. It’s that women are strong.” - Laure Stavoe Harm

There was a marked decrease in the Cesarean rate in the 1990’s that resulted from a big push to encourage and allow VBACs.  Now that trend has changed despite the research showing that VBACs are actually less risky for mom and baby than repeat elective cesareans.  Now it is not uncommon for OBs and even entire hospitals to not support or even “allow” VBACs.  

With her first, her induction ended with a cesarean performed under general anesthesia.  The general was necessary because the epidural didn’t eliminate all sensation.  This time around she is much more informed of her options and her mian difficulty has been finding a provider who will even “let” her have a shot at VBAC.  I think she is currently with her third provider this pregnancy. Right now her main focus is hoping that all of her provider’s VBAC supportive talk  early on will hold as her due date comes and goes.

TIME magazine has an excellent article about the difficulty many women are having trying to find a way to have a VBAC in our current system.  The evidence shows that it is much less risky for healthy mothers and babies to have VBACs rather than routine repeat cesareans.  Henci Goer writes about what medical research shows to be the true risks and benefits of VBACs.

Once the baby is born I’ll let you know how everything went for my friend.