Wednesday, January 7, 2009

Cesarean Births: Preventable?

I'm home, and everyone's healthy: a state of affairs that hasn't happened much over the past two months! I am caught up on email and reading blogs and online newsletters (whew!). It was a lot of interesting reading, which, over the next week or so, I'll be providing links to so you can read too if you've missed it, say, because someone's been sick or you've been traveling!

I have read a lot about cesarean birth in the past several weeks. Many readers have probably heard stories about emergency cesareans - when something happened with mother or baby which made a very fast procedure necessary. I'm thinking about cord prolapse (when the baby's umbilical cord slips past the baby's head is being compressed during contractions) or placental abruption (when the placenta detaches prematurely), for example. In an emergency situation, the time from indication to decision to incision and birth is very quick - a matter of ten or fifteen minutes.

These emergency situations represent a very small number of the cesarean births. Much more commonly, cesarean births are urgent or they are the end result of a series of mother or careprovider choices, many of which are not openly acknowledged by care providers as increasing the risk of cesareans. Check out this very useful discussion defining types of cesarean births - moving beyond "unplanned = emergency vs planned = non-emergency" at Enjoy Birth.

In fact, there is wide belief that many of the cesarean births happening in the United States right now are actually preventable. The World Health Oranization recommends a cesarean birth rate of 5-10%; at rates higher than 15%, the harm to mothers' and babies' health statistically outweighs perceived health benefits for the group as a whole. The United States is well past the "harm outweighing the benefits" range, with most hospitals performing a (very unusual) low of 15% cesarean birth to the average ~30% and some doing Cesareans for 50% of women's births.

The Lamaze newsletter "Building Confidence" for Week 30 mothers has an excellent assessment of preventable cesareans,
"Talk with almost any woman who has had a cesarean and she’ll say her surgery was necessary. Indeed, by the time many cesareans take place, the surgery has become necessary—either because the baby is signaling distress or labor is not progressing. But if you take a closer look, you’ll see that these problems often occurred as side effects of the way labor was managed. Some cesareans can be prevented with care that supports—rather than interferes with—the normal processes of labor and birth. By talking about “preventable cesareans,” instead of “unnecessary cesareans,” we can point to specific choices and care practices that might change the course of labor."
Lamaze offers excellent information about The Six Care Practices that Support Normal Birth.

Choosing a care provider and birth place can be a process, approached in a similar way to other big decisions, like buying a car. A person might go through a process like this to buy a car: deciding what qualities in a car are important - size, fuel efficiency, price, longevity, style; finding out which cars match their priorities; trying to find a reputable place that sells this kind of car; getting the car checked out and then buying it. This process, in my opinion, is much more likely to result in a car that matches a person's needs compared with a process which simply involves driving to the closest car dealership and asking the first salesperson to show you a car and buying it after a brief look-see.

Reading and asking questions about birth, discussing options and the typical routine care offered by a care provider/birth place is of critical importance, in my opinion.

If you're looking to minimize the likelihood of a Cesarean for your first birth experience, think about how to minimize the likelihood of having one of those preventable Cesarean.

Read about the six care practices in the link above. Read independent blogs and books and magazines.

Choose your care and birth place carefully. Understand that not all the care provided by hospitals and doctors/midwives is equal in preventing preventable Cesareans. For example, many hospitals automatically hook women up to electronic fetal monitoring (EFM) devices for all, or the majority, of their labor and birth experience. But in that same Week 30 newsletter, Lamaze excerpts this study,
"Continuous electronic fetal monitoring is used in more than 90 percent of labors in the United States. However, decades of research show that this ubiquitous machine does not live up to its promise of safeguarding babies in labor. In fact, researchers who evaluated all of the published studies comparing continuous fetal monitoring with intermittent auscultation (a method where a provider listens to the baby’s heartbeat regularly throughout labor) found that, when the mothers are healthy and labor is uncomplicated, there were no differences in important outcomes for babies regardless of the method used. However, their research confirmed that intermittent auscultation has a major advantage—it results in far fewer cesarean surgeries.

Source: Alfirevic, Z., Devane, D., & Gyte, G. M. (2006). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, 3, CD006066."
Take independent birth classes instead of the ones offered by the local hospital! Independent Childbirth offers insightful commentary on the cesarean epidemic in the United States, and the role of independent birth classes. If you're in Central Maine, consider calling me at 512-2627 to find out about the independent classes I teach. If you're in Southern Maine, consider calling Birth Roots at 772-4784. If you're outside of Maine, visit the Independent Childbirth Educators directory, or google search independent educators near you. You may not hear about us from the local hospital or doctor's office, but ask a midwife (especially a homebirth midwife); ask at your local health food store; ask at a La Leche League meeting: we're out there!

** Edited to add a link to this great birth story that serves as a real life "illustration" of the topics in this entry: Floppy's Birth.

Christina @ Birthing Your Baby
Independent Childbirth Classes for Central Maine

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