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Aug302008

Article on Elective Cesareans: Some Thoughts

Mums Accept More Risks Than Docs speaks about a study that looked at natural birthing intentions between patients, doctors and nurses. The article really has a lot of information, so I encourage your reading it. I would love to quote the whole thing, but that isn't appropriate. Here are a few excerpts:

102 pregnant women, 84 midwives, 166 obstetricians, 12 urogynaecologists and 79 colorectal surgeons were included in the study. Participants were asked to rank 17 potential complications of vaginal delivery, including severe anal incontinence, severe urinary incontinence and vaginal prolapse, to determine the maximum level of risk they would be prepared to accept before opting for an elective Caesarean.

The researchers found significant variations between the groups. Just 2% of pregnant women indicated that they would prefer an elective Caesarean, compared to 11% of midwives, 21% of obstetricians, 44% of colorectal surgeons and 50% of urogynaecologists.

All of the groups ranked pelvic floor problems the highest as a motive for requesting an elective Caesarean over vaginal delivery. The risk of having to undergo an emergency Caesarean was ranked higher as a motive by doctors than the pregnant women.

It appeared that pregnant women were also more willing to experience pain in labour and perineal discomfort.

Midwives’ views were more closely aligned to those of pregnant women, while urogynaecologists and colorectal surgeons were prepared to take very low risks before they would opt for an elective Caesarean,” the researchers explained.

Commenting on the study, Prof Philip Steer, editor-in-chief of the journal where it was published, said that the findings may indicate that doctors ‘are biased by their inevitable involvement in complex cases, or labours where things have gone wrong

I was asked to comment on this specific article, I suspect because someone would think I would hurrah what they were saying.

However, I am not surprised at all by the study. Are you?

It's interesting how the study was reported, too. Barely mentioning that doctors might have a different view because of their "involvement" with the complications they see. Well, of course they are biased! What they see are the complications, the women who need help, listening as women cry and lament their experiences in birth. It must seem that so many women need help, why would anyone put themselves through all that?

OBs surely see more of the complications than midwives (who have a pretty low rate of considering an elective cesarean)... one, because they have more complicated cases, especially in Europe. I am not sure how midwifery works in Australia, where the study was performed, but if it is similar to Europe's model, I absolutely understand the myopic view of complicated birth. Secondly, doctors perform more instrumental deliveries and episiotomies than midwives (who do no instrumental deliveries) and those can cause serious pelvic floor damage. Because they see more damage (even if it is iatrogenic), they must be thinking, "I don't want that to happen to me!" and, instead of working to create a birth where damage isn't (almost) a given, they assume a cesarean will avoid all those annoyances.

The doctors interviewed also do surgery and therefore, surely are de-sensitized to the risks of surgery. It is an everyday occurence, what's the big deal? I think that there is a period of healing OBs miss - the part where there is so much pain the woman can barely function, but was told it would be normal so she doesn't call. The OBs see women about 4 days postpartum and not again until 6 weeks postpartum. A whole lot happens in that interim, including amnesia of the pain once the woman sits in front of the doctor 45 days after the birth as s/he asks if she is in pain - present tense, not past. Visits are so cursory and so focused on the immediate issue (birth control, Pap), that emotional changes/concerns are rarely addressed.

Midwives, on the other hand, see women much more frequently and certainly speak to women more than OBs. We, by nature of the profession, are brought into the woman's experience as she processes her pain and disappointment. I believe if OBs saw women in the middle of that really excruciating time, they would think differently about elective cesareans.

No, not surprised at all by the article. To women, the complications are, for the most part, theoretical and an unknown. For MDs, they know what is involved. I don't think women fully realize the implications of the complications - that anal problems can mean pooping without warning... in public as well as at home. It can mean having to physically scoop out the poop (with your own hands) every time you want to have a bowel movement. Sometimes for MANY months (or years) before surgery is able to be performed. Women without insurance or money are screwed all the way around. Incontinence can mean dribbles or flows - living in pads sucks. Not having sex with one's spouse evolves into resentment, anger and all too often, divorce. I believe if these facts were disclosed in the study, women might have thought again about an elective cesarean.

That pain isn't a huge issue doesn't surprise me. Women are strong! Docs tend to see labor as suffering, whereas most women grasp the work-benefit of it all.

Read the article and then tell me what you all think.

What would I do? If I *knew* I was going to have something, I would absolutely have a cesarean. If I had anything like I described in a previous birth, I would have a cesarean. I wouldn't schedule one... I'd want to go into labor... but I would not want a repeat of an experience that involved an enormous amount of pain and embarrassment. If I didn't know what was to come, I would have a vaginal birth - and fix whatever happened asap.

What about you?

Reader Comments (9)

I wasn't expecting you to hoorah... I actually didn't think you'd like everything it was saying. It wasn't just the article itself, but also the comments from the writer at ParentDish that made me a bit irritated. Anyway, thought you'd be interested to read it either way.

August 31, 2008 | Unregistered CommenterAshley

And I was! Thank you for sending me there. I hope I had some thoughts that added to the discussion.

Thanks, Ashley!

August 31, 2008 | Registered CommenterNavelgazing Midwife

If only there was a foolproof way to tell ahead of time which births are going to go well, and which ones are not. Alas, it seems like we are forever stuck in a balancing act between unnecessary cesareans and preventable birth injuries.

August 31, 2008 | Unregistered CommenterCarbon

If I had to treat leaky anuses or prolapsed uteruses as a result of vaginal delivery every day I probably wouldn't want to attempt it either! But that being said, I think there is a mindset that most medical pros have completely unrelated to birth in general that leads them to think that the controlled (sort of) process is preferable to the uncontrolled (sort of!) process of vaginal delivery. But I'm guessing I'm preaching to the choir here.

August 31, 2008 | Unregistered CommenterFreya

I stopped visiting ParentDish aka Blogging Baby about 6 months ago. Got too clogged by, well I won't say.

The article is a big duh. I know doctors like to control as much as possible, to limit variables - and we know that each person in this world is a universe onto themselves in terms of reaction to medications, healing time, complications... We are not quantitative or finite, and we change over time too.

I didn't think when I was willing to have a c-section after a painful 24 hour induction that I would soon be experiencing severe intestinal pain. There is no way to prove it but I do believe that the stress of the surgery pushed my immune system over the edge and that's why I have celiac disease today. In fact the whole thing pisses me off. But, I can not blame myself, my doctor or the c-section - not directly. Since I am a changing creature with genetics and environment acting on who I am, there are many reasons why I got here - so too for all the other complications one might experience with vaginal birth.

It does seem to me that the response of the doctors is short sighted in terms of the long term health of the patient and the patient's children. If we looked into the choices of women who have had c-section I bet there are a lot of long term risks associated with having a c-section for her and her family that are not acceptable. It makes me think about selection pressure and evolution, or even reaction barriers to confirmation changes in molecules - but if I tried to explain that imagery I would really bore you. To put it mildly, there are low points and barriers to those low points, energy that must be put into the system, and all kinds of variables in a landscape that is poorly identified to us right now.

August 31, 2008 | Unregistered CommenterEthel

You wouldn't bore me! I think what you are saying is fascinating. I think I understand on a basic, elementary level, too.

And you are right. I think the counter-study should be asking post-op cesarean moms... at ALL stages of recovery... if they would have an elective cesarean for their next baby.

Great thoughts from everyone. Thanks.

September 1, 2008 | Registered CommenterNavelgazing Midwife

I don't think the results are surprising, but I do think the answers from the mothers are somewhat skewed by not having actually experienced some of the worst outcomes (as the doctors are skewed by having more exposure to the worst outcomes). I suspect most women who actually have anal incontinence as a result of damage from a vaginal delivery wish they had had a c-section. But most women with vaginal deliveries, even difficult ones, won't have anal incontinence. And do you subject yourself to the risks and pain of a c-section for a hypothetical? Oh, for magic vision to see into the future.

I have a friend who tore really badly with her first birth. She saw that first little glimpse of the head in the mirror - when it's just a quarter-sized spot of hair still fairly high up, got motivated and birthed her daughter in two enormous pushes. The tear almost went all the way through to her anus. It was bad enough that her midwife sent her over to the hospital from the birth center to get checked out. While she now feels very committed to having another vaginal birth, in the months immediately afterward, she was saying if she ever had another baby, she would strongly consider a c-section. She has a cousin who became incontinent after a very difficult vaginal birth, and knowing someone who had that experience made her very concerned about tearing along the scar, and really tearing all the way through the next time. She's fine now, 18 months later - no pain with sex or anything - and I think that is what allows her to consider another vaginal birth. If she had permanent complications, I'm not sure how she would feel.

September 3, 2008 | Unregistered Commenterchingona

Late to the party, as usual...
I happened to catch an episode of "A Baby Story" the other day, and the mother giving birth was having a planned Caesarian with her second child due to a 4th degree tear during the first child's birth. She had gone without pain meds and was so exhausted by the pushing stage that she couldn't finish up on her own. The doc used a vacuum to get the baby out, gave her an episiotomy, and everything just went to pieces after that, literally and figuratively.

I felt a lot of sympathy for the woman since this could have been me 4 weeks ago. Went totally unmedicated with a hospital-based midwife, and even though the baby was doing fine, the contractions were starting to peter out in the pushing stage. I was so exhausted after about 16 hours of active labor I didn't think I'd be able to get the baby out on my own. And for whatever reason, I wasn't "getting" how to push. Fortunately, I did manage to get her out after about 3 hours of pushing with a 2nd-degree tear -- vagina, labia, and perineum, but the anal sphincter was completely intact. Having child #2 is still probably 3 years away, but I'm debating whether I want to go through this all again due to fears about whether the repair will hold up or be worse the second time around. I feel extremely lucky to have had no damage to the plumbing, and that I was up and out of the house with the baby after 5 days.

BTW, Barb, you may remember me...I emailed you near the beginning of my pregnancy (January-ish) about whether I could birth with a midwife even though I had no thyroid. Here's some baby pics if you wanna see...

http://www.flickr.com/photos/10618371@N03/

September 16, 2008 | Unregistered Commentericedancer

You sure do travel a lot! WOW! Beautiful pictures.

Oh, and your baby is adorable!! *laughingwink*

I had a 3rd degree mediolateral episiotomy with my first baby and did fine with the other two. Some small tearing with Meghann (who was 10lbs 6oz) and none at all with Aimee (8lbs 13oz). So, just because you have tears/epis one time doesn't mean you will do it the next. Lots has to do with positioning (be on hands and knees or standing, not squatting, that helps lots), the baby's positioning (not a lot we can do about that) and the luck of the draw.

I can totally understand the woman you saw choosing a cesarean. I can't imagine having to contend with so much pain and embarrassment for long, long after the postpartum should have been way over.

No worries on being "late." You found and are reading back through the NEW blog site! I love it! Thanks for following me here.

Beautiful baby... just adorable.

September 16, 2008 | Registered CommenterNavelgazing Midwife

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