It’s true in my area. We’re relatively rural, and the biggest hospital still doesn’t have the capability to respond quickly enough to a ruptured uterus in the middle of VBAC labor. They did VBACs for awhile, and then decided the risk was too high. What would you have these hospitals do? They used to like VBACs most of the time; they’re usually safer, and much cheaper. But then you get that case every so often that goes horribly wrong, and you have a dead mother and child on your hands; I can understand why scheduling c-sections starts looking like a better option. And that’s before you look at malpractice suits, the threat of which hangs so heavily over OB’s heads that there aren’t enough OBs to go 'round in some places. AFAIK malpractice lawsuits are also a major reason for the reduction in home births and midwives who do them.
I’m speaking from the opposite side of the fence; I had my first c-section after 24 hours of labor, and DangerGirl was over 10 pounds and turned the wrong way. She never got anywhere, and was in trouble by the time they got her out. So I’m quite grateful for my c-section, since it nicely saved both of us from a gruesome and exhausting death, and I didn’t find the recovery that bad. My second birth was scheduled for 10 days before my due date, and went very well, producing a baby over 9 pounds. The recovery was downright easy–though my stomach muscles are kind of a mess, I don’t think they would be in great shape anyway. I would have liked to try a VBAC, but I wasn’t even a good risk, producing giant babies the way I do. After both of my experiences, I have a good deal of respect for my OB and his advice. I really don’t mind the way things have turned out. I plan to have another baby, anyway.
In all fairness, however, there are a number of things that can go wrong in any labor, including catastrophic rupture to an unscarred uterus, cord prolapse, placental abruption, undiagnosed footling breech…these are all emergencies. The middle two are not all that uncommon (together, they are certainly as common as the risk of uterine rupture in VBAC). If the hospital cannot respond in time to VBAC emergencies, they cannot respond in time to ANY emergencies, and honestly, how can they justify offering L&D services at all? If they can respond in a timely manner to something like cord prolapse (which is immedicately life-threatening, and can happen to any woman in any pregnancy without warning), why can’t they respond in time for a VBAC emergency?
“What if she wants to have five or six kids, and got stuck with a breech presentation in the first pregnancy, a circumstance unlikely to recur?”
As I hope you’ve learned via this thread, you’re wrong to attribute those future c-section requirements to a doctor’s fear that future pregnancies will be breech.
That’s not the case at all. It’s because of a perceived risk of uterine rupture, as has been discussed. You may argue with their risk analysis, but please stop thinking that subsequent c-sections are necessarily prescribed because a doctor assumes the same birth complication will be repeated over and over.
As for c-section recovery, it’s pretty speculative for an individal to claim her vaginal delivery was easier to bounce back from simply because it wasn’t a c-section, or to claim her c-section recovery was harder because it wasn’t a vaginal birth. That is, you don’t know how your body would have recovered in the other circumstance, because it’s a big hypothetical. Moms who have had one of each type have something slightly better to go on, but they’re still guessing. Labors and deliveries may not be the same for each woman each time. And many unplanned c-sections happen because something went wrong or seemed difficult. For example, a long labor that didn’t progress. In that case, a natural delivery after days of labor (and probably long, difficut hours of pushing, due to exhaustion) is probably still going to a REAL BITCH to bounce back from. You just don’t know.
As for me, I think I did pretty well recovering from my c-section all things considered (and I had some complications), but I have no idea what it would have been like getting over a vaginal birth under those same labor circumstances. I’m not planning to get pregnant again, so the VBAC thing is moot for me.
I was thinking about this thread a lot today. I never had a vaginal birth to compare to - just the C sections… but if I had ended up with a ruptured uterus I believe they immediately perform a hysterectomy thereby making it impossible to carry any more children. If I wanted to have 5 or 6 kids after a Csection I believe each delivery would have to be considered on its own merits and I wonder how safe VBACS are after a number of pregnancies stretching the uterine muscle to such extremes?
Oh and about those “trophy coochies!” The hormones that tighten all your muscles back up after birth wreak havoc on a vagina that hasn’t been stretched by the birth process. For me sex was awfully painful for a while afterwards.
Well, I lack your medical background, but this assertion doesn’t make sense to me.
You’re saying that any hospital must be able to respond to all labor emergencies with equal confidence and success or no babies should be delivered there.
Are these things so equivalent? Are all labor and delivery emergencies equally life-threatening, take the same amount of time to go from serious to fatal, require exactly the same level of interventions and expertise? Is it not possible that some labor and delivery emergencies, while life-threatening, have a greater possibility of being successfully solved? And that those which are especially dangerous are the ones the doctors work hardest to avoid (setting aside whether or not we agree with their methods or efforts)
That’s certainly true of many other problems in the body. Some heart problems are life-threatening but can be treated. Others will kill you even if you’re in the best care. Hospitals can more effectively treat some rather than others. Would have them refuse all cardian care, then, until they can handle aortic ruptures as successfully as other heart problems? And is labor and delivery so different, then?
Crikey, my wife’s midwife for our kids has a three percent transport rate (home births transported to a hospital)! Sure, there are times where a cesarian is advisable and a responsible midwife will screen out any high risk births (and being neither a woman or an OB, I don’t have a dog in this fight), but for over a quarter of our nation’s births to be by c-section seems excessive to say the least.
That’s interesting. I feel exactly the same way, except that I was “steamrolled” into a vaginal birth when I should have had a c-section.
I beg to diffah. I think the worst of both worlds is what happened to a friend of mine–she was having twins, had the first vaginally, and had to have an emergency c-section for the second. Can you imagine recovering from both at once? Zoinks. Good news is that both babies were healthy and mom recovered just fine and even managed to nurse.
Here’s where it becomes problematic. The libertarian side of me says “whatever works for you.” But the realist in me knows that the more women who choose elective c-sections for their first (and likely all subsequent) births, the more the option will be promoted and presented as something totally inconsequential, like choosing whether you want the pelvic first or the breast exam first when you go for your annual check-up.
It already is, in some important ways. Women are being told that the risks involved in an elective c-section are no greater than the risks in a normal vaginal delivery, or that the difference is minor, ignoring the whole host of risks that simply don’t exist in a vaginal delivery because it’s not a surgical procedure done under anesthesia.
This feeds into the situation mentioned in the OP. The more women having c-sections, the more women who are going to run into the anti-VBAC wall. The more women having optional c-sections, the more support there is for the position that having a c-section is not a big deal, so all of the women who wish to have the opportunity to have even attempt a VBAC are going to run into an ideological obstruction, because the “common sense” response is going to become (and is becoming) that a c-section is no big deal, so why are they so upset that they’re having the birthing option that they want denied to them because of insurance problems?
You’re free to make choices, but you must realize that your choices have an impact on others. Your choices aren’t made in a vacuum. And when you schedule a c-section – especially for a frivlous reason, not fear of the pain of labor but fear of a stretched our vagina kind of thing – has a negative impact on every woman whose concern is the very unfrivolous overall recovery and health of both herself and her infant.
Qadgop raises a good question. Should a doctor tell women up front? Absolutely. Should they be forced to allow trials of labor if they’re not “comfortable” doing so? No. But doctors should base their decisions on the science and the facts in front of them, not their “comfort” level. And certainly not on their insurance premiums.
And for an entire hospital to refuse VBACs across the board? It’s very problematic to me when a facility administratively prohibits patients and their doctors from making medical decisions together based on their individual situations instead of statistical abstracts. If the doctors who work in the hospital would offer VBAC were it not for the ban, it’s a pretty good indicator that the decision isn’t because the hospital wasn’t physically equipped to handle VBAC emergencies.
Clearly, I have failed to communicate something here.
Some cesareans are undeniably necessary. I had one of those (twins, one in distress, presenting twin breech). That circumstance is highly unlikely to repeat in anyone’s life. However, in many locales, women with perfectly healthy, normal pregnancies, with babies in optimal position for vaginal delivery, will still have their babies surgically removed because of a previous cesaean. This is being done for liability reasons (insurance companies refusing to insure hospitals to offer VBAC, for instance) as a blanket policy, and not on a case-by-case basis.
And the perceived risk, by the way, isn’t even evidence-based. The study out of the University of Washington in 2002 didn’t tell us anything we hadn’t known for years: that women who have prior cesarean scars should not be induced or augmented with prostglandins, pitocin, or misoprostol. But it got spun badly in the press, and suddenly everyone’s running around waving their hands wildly, thinking VBAC is going to kill women, while cesarean surgeries are as safe as cutting your nails. It’s not true. Both carry risks. You’ve just traded one set of risks for another, which by the way is less likely to get the hospital sued. It’s not about safety. It’s about money.
Actually, absolutely their insurance problems. Some physicians stop practicing because they can’t afford the malpractice insurance - now, is it better to have a doctor who will only do a c after a vb, or no doctor at all because they went out of business due to the insurance premiums?
In a perfect world, this wouldn’t be an issue. But we have to live in reality.
My brother in law is a CRNA. He’s participated in thousands of births. At one time he was independant. His malpractice insurance was a huge expense (I can’t remember how much, so I won’t quote) - and he wasn’t the doctor.
That’s an utterly alse dichotomy. The answer is neither of your scenarios, but to eliminate the stranglehold that the insurance industry has over hospitals and doctors. No company should be able to make it impossible for a hospital to serve its patients in the way that their individual doctors see best.
I’m horrified at the fact that so many people are willing to roll over and say “Oh, it’s reality, some actuary at MegaProfit Insurance Company says I can’t give birth naturally even though there’s no medical indications against it, so I guess it’s just not meant to be.”
Not sure “clearly” fits here, because you’re not addressing my point. My point: It has always been my understanding that there is one major reason why doctors/hospitals often require second cesareans before knowing whether or not they would have been medically necessary: a perceived increased risk of uterine rupture. Maybe they are wrong, maybe U-W has it right; all of that is beyond this particular point. The point is WHY doctors do this, not whether they are right.
You simply and clearly stated (see quote above) that a doctor will require a second cesarean because of a fear that the same complication encountered in a previous labor will recur (or, at the very least, this is the case for breech presentation), which you then rightfully dismissed as unsound thinking. And I simply corrected that belief, because until you said this, I had never heard that doctors require second c-sections because they worry about a second breech (or a second CPD, or a second cord prolapse, or what have you). That may be because my previous knowledge was incomplete. If I’m wrong, please correct that.
Your uterus can rupture?!?!
<aurelian hides under the desk>
Holy crap!! The thought of having a baby already terrifies me, and I didn’t even know that was possible! (hugging belly) Would someone mind explaining why/ how that happens?
My mom was in labor for 30 hours, and she tore. :eek: (I cannot even express how much that freaked me out when I found my dad’s detailed notes on the delivery in my baby book.) Elysian mentioned that
Given that I learned this in health class many moons ago, it’s not the most reliable information, but aren’t episiotomies supposed to prevent tearing, and give the baby more room? Again, would someone enlighten me?
Actually, what I thought I simply and clearly stated had a context. Here is the context (please go back and see the post, if you doubt:)
The context is, once a cesarean, always a cesarean. Perhaps the first one is for a genuine medical reason - it happens: breech, cord prolapse, fetal distress, face or brow presentation, persistent posterior, maternal exhaustion or distress, etc. No problem. The problem is that all subsequent surgeries will be required because the first one had a genuine medical reason, not because the specific secondary (tertiary etc) pregnancy itself presents the kind of circumstances that would require surgical intervention. I’m not sure why this is unclear. I can keep trying to explain it from different angles.
Any muscle can tear. If I remember correctly, uterine muscle is smooth muscle, and the general direction of contraction is down, which is along its line of strength. I don’t think I’ve ever heard of a spontaneous uterine rupture in an unscarred uterus, before labor or in labor, in the absence of tocolytics or prostglandins provided as augmentative, or inductive, stimulants. (I’m sure such things have happened, but I’ve not heard.) What I have heard of are ruptures associted with pitocin or misoprostol (the latter, even in women with unscarred uteri). And, I have heard of ruptures of the scarred uterus. Now, before you totally freak out, the majority of these “ruptures” are in fact “deshiences” - windowing of the scar. Think of stretching a plastic bag or 6-pack ring until the plastic gives, stretches, thins. It will break if stretched too far, but it will ‘window’ first. These are not life-threatening. What is life-threatening is when the muscle itself tears, or the scar itself gives way. Here’s a much better page explaining it.
It is extremely likely that your mother tore badly *because * she had an episiotomy, not because she should have had one and didn’t. Almost all women did, back then. God knows my mother was cut “from stem to stern” as she calls it. It was standard OB practice, and some doctors still do it that way. But here is a page that explains the myth behind the method complete with references to peer-reviewed journals and studies.
What an episiotomy can do is direct a tear toward the rectum, or sideways into thigh muscle, and away from the urethra or labia. What it cannot do, by very definition, is prevent one. Think of it this way - if you have a piece of fabric, and you try to start a tear along its edge by pulling, it will be difficult. But place even a small nick in the edge, and it will be easy to tear. Worse, an episiotomy always cuts through several layers of muscle which run in different directions. This is something a natural tear is less likely to do.
A cut is easier to sew up, but harder/slower to heal from. The scar may be more likely to give way in future deliveries (I don’t know). Anyway, I know I tore very badly when my daughter was born (I told the doctor I preferred to tear naturally if I must tear, than be cut, and she followed my wishes). However, if my daughter had descended slowly, and had not been being pulled by the doctor, and pushed by me, this might not have occurred. I don’t know. Ideally, the birth attendant will provide support, and moist heat to the perineum as the baby descends slowly, and the mother will push slowly enough to allow the tissue to stretch and give. This doesn’t happen usually, but tears are far less likely when it does happen.
As for the episiotomy giving the baby more room, this is generally not the case. What it does, is give the doctor more room for the introduction of forceps etc., or speed delivery by (I think) about 15 minutes. Unless the baby is in distress, the only value I can see in that 15 minutes is so the doctor can go somewhere else. It is true that sometimes the perineum will not stretch enough to accomodate the fetal head circumference, and in such a case the tissue will naturally tear or be cut, but I think this is the exception.
When my mother was pregnant with my brother, the doctors were extremely wary of allowing a vaginal birth, as I had been delivered via emergency cesarean (heart rate decrease) two years earlier. I believe the reasons given were worry about rupture. It was a moot point anyway, because they took him by planned cesarean two weeks early. If they hadn’t, he would have been 11-12 pounds at full term. :eek:
Of course, that was 1986. I’m not sure how things are handled now.
I think most doctors would insist on a section for fetal size. However, the real question is “what is the circumference of baby’s head” rather than “how much does he weigh?” Fat squishes. Also factors are the position of the head, whether the mother is able to move into positions that feel right to her, whether the labor is permitted to proceed naturally (allowing the fetal head time to mold as needed), and so on. There is always a risk of shoulder dystocia (shoulders get stuck), higher with larger babies, but many of these can be managed with positioning of the mother. Still, most doctors would remove the baby surgically for being this size, period, whether the mother had a cesarean previously or not. (Even so, many women birth babies that size just fine, so size of the baby is not an absolute predictor of ability to pass through the birth canal.)
I guess I just read your post narrowly. When you expressed exasperation that one should have to have a c-section even though a breech may never happen again, I could find no other way to read your comment. That is the only comment that drew me in that direction, and while I appreciate your offer to explain your “context” over from different angles until I glom onto it, I really don’t think it’s necessary. I believe I just read that sentence far differently than you meant it. It looks like we both agree that recurrance of breech has little or nothing to do with the “required” c-section trend. You were espressing some sort of irony, which I took a a different way.
Where so many of you see despair, I see some hope. Not all the doctors I’ve heard about are “bastards” who are too quick with the knife for episiotomies or c-sections. I’m not as pessimistic as some are about where this trend is leading or how far it will go.
In addition to the midwife option, some of you might want to try a family practice doctor instead of an OB/GYN.
Women who are so deeply traumatized by c-sections that they will stay home and attempt to have their babies away from any variety of trained attendant are hopefully in a miniscule minority. Changing policy based on their extreme over-reactions falls pretty short of any standard of “evidenced based” medicine. They should seek some sort of counseling and get emotional healing before getting pregnant again. Actually, there are probably a number of women (and men) who could benefit from a little counseling about their labor/birth experience (even if they are nowhere near as emotionally upset as some are).
Except that if the local hospitals disallow VBAC under any circumstances, it makes no difference who you choose as your caregiver, unless you want a home birth. And of course, homebirths are illegal in some places. In others, CNMs are forbidden to attend VBACs, and so on.
I don’t know what’s the matter with my computer. I’ve had to retype this 3 times and it keeps vanishing, so here I try again.
I think counselling is a wonderful thing. I saw a terrific ‘birth trauma’ counsellor myself during my twin pregnancy, as the issues from my first cesarean were making my emotional state during my second pregnancy a real problem for me. I did not complete that therapy due to complications with the twin pregnancy, and anyway, they were born by cesarean for very pressing medical reasons. What she did mostly was to affirm my perceptions and feelings and to confirm that yes, I had not been treated well, and I should not have had to go through what I did. Oddly, though I thought I had dealt with my issues when I was expecting never to have kids again after the twins, a lot of them surfaced again when I found myself unexpectedly pregnant with my 4th. So there I was, back in therapy, scared to death I would be dehumanized again, steamrolled again, dismissed again, depersonalised again. I cried a lot. I worked with the counsellor to sort out the things that were vital to tell my doctor. And my doctor and I talked about those things. And she listened. That was so very important.
What would not be useful, however, is “counselling” that is designed to convince the woman she didn’t feel what she felt (or else, that her feelings are irrelevant) in order to create a compliant patient who will meekly submit herself to a repeat of the first experience as a matter of policy. But what do you say to a woman who has been severely traumatised, when the fact is, she will be forced to face a repeat section merely as a result of hospital policy? It’d be bad enough for her if it were necessary…how is she supposed to deal with it when it’s not? How about the women (I know several) who endured cesareans without anaesthesia? How do you counsel them that they *must * face that same kind of situation again (even with the promise of actual pain relief)? I’m sure I don’t know the answer to that.
Clearly, hospital policy should not be made based on a few individuals. But on the other hand, you can’t say “It doens’t matter what trauma you experienced, you got pregnant, you’re going to have to do it again.” I mean, OBs will offer cesareans to women who had traumatic vaginal births. But in some locales, they will not (cannot) offer vaginal births to women who have had traumatic cesareans.