Wednesday, December 30, 2009

Planned Cesarean Delivery Offers Protection Against Pelvic Floor Disorders

Press Release by

Dec 28, 2009 – A new study published this month warns that pelvic floor disorders are set to increase substantially in America over the next 40 years due to changing demographics.(1) Pauline McDonagh Hull, editor of highlights medical studies that demonstrate an increased risk of these disorders following vaginal delivery (VD) and a protective benefit with planned cesarean delivery (CD), plus evidence that women are not being informed of these facts.

You can read the full press release here.

Wednesday, December 23, 2009

Criticism of promoting cesarean delivery on request

A number of bloggers and birth educators have been discussing (and applauding) a recent commentary by Nicette Jukelevics, MA, ICCE, called 'Putting Mothers and Babies at Risk: Promoting the Elusive ‘Cesarean Delivery on Maternal Request’'.

In it, Nicette Jukelevics asks questions including 'Maternal Choice or Physician Choice Cesareans?', and I completely understand that this is a genuine concern for women whose first choice is a vaginal delivery.

However, for me, the most important aspect of her commentary is its 'suggested Patient Information Form', which Jukelevics would like every pregnant women to read, answer the questions and then sign, in order to 'accurately demonstrate that she is choosing a cesarean section that is based on informed consent.'

Patient Information Form
(Surely this is needed for cesarean AND vaginal delivery?)
I actually like the idea of such a form, and while I would like to see some modifications in the set of questions proposed here for maternal request cesarean delivery, what I am even more interested in seeing is the proposed Patient Information Form for pregnant women to read prior to choosing a planned vaginal delivery (primary and VBAC) - in order to ensure that this too is based on informed consent.

I appreciate that my request for equality in aiding informed decisions of both cesarean and vaginal deliveries will strike many birth educators as unnecessary - they may believe that the decision to plan a vaginal delivery is the norm or given, and it is only cesarean delivery 'pushed on women by obstetricians' that requires informed consent.

I disagree.

I believe that the risks associated with planned vaginal delivery - whether spontaneous, instrumental or eventual emergency cesarean delivery in its outcome - are often underestimated or ignored by birth educators, and that women are not consistently informed of the potential negative health implications (physical and psychological) for their babies or themselves.


Monday, December 14, 2009

My interview with BBC Radio Wales aired this evening

Retired urologist Christine Evans interviewed me for this special programme in which she sets out to explore whether cesarean deliveries on maternal request are justified.

The programme is called 'The Irritated Consultant' and it's Episode 4, '...caesarian births under the spotlight.'

Christine concludes that a woman's autonomy in making an informed decision is legitimate, particularly when she is older (35 years or more) or has had medical help to conceive.

You can read details of previous radio and media interviews here.

Friday, December 11, 2009

Barbaric - and untold - aspect of vaginal delivery

This is an horrific story from China about an 18-year-old mother who was given more than 100 stitches - some without anaesthetic - at the birth of her first baby.

According to a China Press report, 'the woman was stitched up by a lady doctor and a trainee doctor after giving birth. However, a medical officer later removed the stitches, saying the wrong threads had been used. He then re-stitched her without anaesthetic.'

Even worse, another senior doctor then 'announced that the thread used by the medical officer was also the wrong one, requiring the woman to go through another process of having the stitches opened and closed again with the right thread.'

It happens in the UK too!
I heard about this happening in the UK some years ago, and in fact continue to be surprised how little attention it is given in the media. According to the Birth Trauma Association, vaginal stitching without anesthetic occurs 'quite often'.

That's true: Many women in the NHS are stitched up following a vaginal tear or episiotomy WITHOUT ANESTHETIC.

Indeed the Birth Trauma Association describes this wholly unnecessary and barbaric birth experience as 'a frequent complaint' by women.

Pregnancy and birth phobia
Unsurprisingly, the young Chinese woman (who 'also claimed that during the process, one of the doctors had accidentally injured her thigh causing her to suffer a three-inch cut') now says that she has a 'phobia about getting pregnant again'.

Birth phobia is often be described as irrational, as though a woman's fear of some of the terrible things that can happen during a vaginal delivery are just 'all in her head.' Well they're not - they're real - and if she wants to avoid even the chance of such terrible things happening to her, then in my opinion, her decision to do so is entirely rational.

Another two babies die because cesareans are not carried out

I read these two stories online today, in which precious babies' lives could have been saved with a cesarean delivery.

The first, by Colin Fernandez writing for the Daily Mail, is titled: ''Chaotic' care led to baby's death', and reports on an inquest into the death of Ebony McCall at Milton Keynes General Hospital's maternity unit.

Cesarean request denied and maternity unit understaffed
According to the report, doctors 'missed two chances to save Ebony's life', and indeed the mother and her family's own request for 'emergency surgical delivery' was 'ruled against'.

Furthermore, staff were 'overstretched as 12 mothers gave birth at the unit that night [and] only four midwives were on duty...'. Eventually, an emergency cesarean was carried out on the baby's mother, who is described as 'rolling in pain' and suffering from other health problems 'including a faulty heart valve, only one working kidney and curvature of the spine.'

The second, 'Jury finds doctors liable in death of newborn', appears in The Buffalo News, and Matt Gryta reports on a $2.2 million award for the family of baby Leah Kreinheder, 'who died of a seizure linked to her mishandled birth'.

Continue with labor and don't do a cesarean!
Despite concerns about 'problems with the baby’s heart rate', the decision was made 'to continue with the labor and not perform a caesarean section'

What happened next is a sadly familiar story - 'the baby became stuck during the delivery and for almost five minutes was deprived of oxygen; as a result, she suffered brain damage and head trauma, multiple bruises on her head and arms and was blue at birth... [She] suffered seizures and was transferred to Women & Children’s Hospital in Buffalo, where she remained for a month.'

I ask once again: How many more babies have to die before hospitals understand that efforts to reduce cesarean rates or avoid 'unnecessary cesareans' can have dangerous and devastating effects?

Wednesday, December 9, 2009

New sealant helps protect from cesarean infections

A new type of surgical sealant is being used to reduce the risk of infection during cesarean deliveries.

This article on the subject focuses on the practice being employed by Dr Jacques Moritz, director of gynecology at St. Luke’s-Roosevelt Hospital in Manhattan, following positive results in clinical trials:

The 'sealant has been shown to seal and immobilize harmful pathogens including MRSA, S. epidermis and E. coli. The sealant is applied to the skin after surgery prep and before the incision is made. The sealant is non-irritating and does not need to be removed in order to close the incision. After surgery, the sealant wears off naturally within a few days. Doctors say the sealant should not be used in surgical procedures involving mucous membranes or the eyes, on patients with hypersensitivity or on skin with active signs of infections.'

Dr Moritz says that, while 'there is no such thing as true sterilization of the skin', this sealant 'gives new moms an added layer of protection.'

It's certainly something worth asking your doctor about ahead of your planned surgery...?

Two Australian babies might have lived if delivered by cesarean

Writing for Adelaide Now, Ken McGregor reports on an ongoing inquest into the deaths of two babies - both delivered by ventouse - in 2006 and 2007.

He describes how 'the babies died of multi-organ failure following a "massive" subgaleal haemorrhage, which may have been caused by the Ventouse machine'. But even more shocking (at least to me) is the reason given by Melissa Sandercock (the senior obstetrician involved) for attempting an instrumental delivery:

She 'told the court that she considered delivering him by a cesarean, but because it was a public holiday and there were no anaesthetists nearby, she decided on using the Ventouse.'

Lessons learned?

Ms Sandercock, says she has 'since changed her delivery methods and now "prefers to use forceps" when a baby shows signs of distress.'

I am not a doctor, but as a concerned mother of two precious children and as someone who values the protection of my pelvic floor during childbirth, the experience described above is just another example of the type of unpredictable vaginal delivery that I chose to avoid when planning my cesarean delivery.

I felt that it was safer for my babies, and I personally didn't want to be delivered via ventouse, forceps or an emergency cesarean. And looking at the increasing rate of elective cesareans in Australia, I think it's fair to say that I am not alone in my thinking.

Tuesday, December 8, 2009

Albany independent midwives' contract terminated by King's College Hospital

The Guardian has reported that London's King's College Hospital has terminated its contract with the Albany group of independent midwives, 'alleging that a disproportionate number of the babies it delivered suffered damage during the birth.'

It says that 'King's decided to terminate the contract after commissioning a report from the Centre for Maternal and Child Enquiries (CMACE) [and it] is believed the investigation was triggered by the death of Natan Kmiecik, one week after he was delivered at Kings by one of the Albany midwives. His mother, who did not speak English, had a caesarean for the birth of her first baby but wanted a natural birth for her second. Her lawyers claimed proper procedures were not followed, because the baby's heartbeat was monitored only by a small hand-held device so she could have a water birth.'

Low levels of medical intervention
While a very positive aspect of the Albany group is its aim for all women to be delivered by a midwife they have built up a relationship with during their pregnancy, it is now in question whether some of its other policies (namely, enbcouraging - almost 50% rate - home births and reduced medical intervention) provide best practice care.

'King's says babies delivered by Albany midwives had higher rates of hypoxic ischaemic encephalopathy brain damage caused by lack of oxygen and lack of blood flow to the brain - than those delivered by midwives it employs directly over the last two and a half years.'

This story reminds me of a UK medical study from 2004, which assessed 540,834 live births and stillbirths in 65 maternity units. It found that a ‘higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates' (Joyce et al, UK, 2004), so it is unsurprising to me that a practice of minimal intervention by the Albany group is reported to have led to negative health outcomes.

Clearly, those women who have enjoyed positive experiences at this midwifery practice are angry and sad to hear this news, and I do have some sympathy for them. But I think it is safe to assume that it was not their precious baby who fell between the cracks and suffered injury (or death) during a planned vaginal delivery.

Otherwise, they might well be interested in reading the Canadian study I blogged about yesterday, which found that 'life-threatening infant morbidity is lower with planned cesareans'.

Monday, December 7, 2009

Life-threatening infant morbidity is lower with planned cesareans

This is a very important study of almost 40,000 term deliveries in Canada. So far, it has received no media attention here, but I think it deserves your attention - especially women who might be worried about a planned cesarean delivery for medical reasons but also women who chose to plan a cesarean and now face a constant stream of criticism by others.

What the researchers did
LS Dahlgren et al studied 1,046 pre-labor, planned cesarean deliveries for breech presentation and 38,021 planned vaginal deliveries with a cephalic-presenting singleton (i.e. a baby in the normal, head-down birth position).

What the researchers found
Life-threatening neonatal morbidity was decreased in the planned cesarean group: ‘elective pre-labour caesarean section... at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery.'

Why is this study so important?
Two reasons.

1) It found that 'life-threatening maternal morbidity was similar in each group'. In other words, that planned cesarean surgery - despite being complicated by a breech presentation - was no more dangerous for mothers than a planned vaginal delivery.

2) Because the vaginal delivery group consisted of straightforward pregnancies and was then compared with a cesarean delivery group of babies in the breech position, the fact that surgery STILL turned out to be the safest delivery method, raises the question how much wider the margin of benefit might have been if the cesarean group consisted of straightforward pregnancies too...

The researchers' conclusions
You can read more about this study, 'Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants', here, but in brief, the researchers note that 'the increased neonatal risk was associated with operative vaginal delivery and intrapartum caesarean but not spontaneous vaginal delivery'.

So, if you have a spontaneous vaginal delivery, your baby will enjoy a safer arrival. Of course the problem always remains that spontaneous vaginal delivery can never be guaranteed. Therefore women need to be advised of ALL the potential health outcomes of a trial of labor (which in fairness, many will legitimately accept in preference to surgery), and not just the 'best case' scenario if everything goes according to plan.

Further research needed
Evidently, as the researchers conclude, the 63% of women who planned spontaneous labour and subsequently achieved a spontaneous vaginal delivery may/'would not have benefited from delivery by caesarean section' (I added the word 'may' since maternal morbidity factors such as pelvic floor damage must be considered too), and therefore it is suggested:

'Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum caesarean section, as this may assist maternity caregivers in decision-making about childbirth. Further research is also needed to determine if these findings can be confirmed in a prospective study.'

Thursday, December 3, 2009

Nurse says: 'Outlaw elective cesareans'

Talk about wanting to have your cake an eat it.

Today I came across this comment on the website, posted by 'LadyJaye' on December 1st:

Re: Elective C-sections- moms idea or the providers?
'I hope my response does not offend anyone, and this opinion is specifically for elective C-sections- they should be outlawed. Doctors who push them for easy scheduling or insurance/ money purposes should have their licenses taken away, and women who do not want to give birth to a baby should not have a baby. It is in my opinion that our bodies were made to have children, and unless there is a medical emergency there is no reason to interfere...'

First of all, the comment 'women shouldn't have a baby unless they're willing to have a vaginal delivery' is offensive.

Secondly, if women's bodies are so capable, and Mother Nature is so reliable - 'our bodies were made to have children' - why do so many medical emergencies occur?

Medical intervention verus Natural evolution
Contemporary women are simply not willing to risk death and/or injury to their babies or themselves, and unlike previous generations (we always hear the argument that 'women have been giving birth for thousands of years, so why change things now?'), we are in a vastly improved position.

We have access to a level of surgical care that is keeping pace with our maternal landscape (think: larger babies, heavier and older mothers) better than natural evolution has managed to do (think: increasingly big baby's head, same narrow pelvis to get through).

Personally, I had more faith in my doctor, and the scalpel in her hand, than the unpredictability of Mother Nature. My decision to choose surgery may mean I hold different views to other women, but it does not mean I'm unfit to be a mother.

For goodness sake...!

Tuesday, December 1, 2009

Iranian women shun natural birth and choose cesareans

This article in The National (dated Nov 29, by Maryam Sinaiee) discusses the situation in Iran, where it is reported that in some private clinics, the cesarean rate is 'as high as 100%'.

The article begins with two interesting statements: 'Some obstetricians in Iran are advising women to give birth by caesarean section' and also: 'Many pregnant Iranian women are choosing caesarean section over natural childbirth, according to health officials.'

Doctors' observations
Says Dr Nahid Khodakarami, a member of the Iranian Medical Council: 'More than 75% of all C-section operations are elective and not required medically.'

Says Dr Mina Afkham, an obstetrician based in Tehran: 'They hear a lot about the pain of natural delivery from their mother and other women and can’t be persuaded to have natural birth, but fear of the pain of giving natural birth is not always their only reason to choose C-section... Giving natural birth has somehow become synonymous with lower social stature for some women. Some others even ask to have their babies on a certain date they choose themselves. I agree that some of my colleagues are reluctant to assist natural deliveries but pointing the finger at them only is far from being fair.'

Women's personal views
Sara Namazi, a 23-year-old pregnant woman in Tehran explains her reasons for choosing surgery: 'I have seen horrible scenes of natural childbirth in movies where women writhe in pain and moan and scream and sometimes even die. Only women who can’t afford the high cost of a C-section now have to go through that pain... Having a C-section will mean that if there are no complications I will walk into the hospital on my own feet to give birth which is much better than being carried there crying in pain.'

Samaneh Fadaie, a 39-year-old mother, describes her natural childbirth experience: 'All my friends thought I was mad and the obstetrician was visibly unhappy with my decision, but I wanted to experience what nature has ordained for women. I endured the pain for nearly two days before I could hold my child in my arms. Not even a single friend of mine has since chosen to do the same.'

I don't necessarily foresee rates of this level in the UK and North America, but I do understand why many doctors have said that national cesarean rates are more likely to increase rather than decrease as we move forward into the future.

Well, apart from increases in the emergency and planned cesarean rates for medical reasons (due in part to a continued increase in older, larger mothers and larger babies), I believe that word of mouth will become an increasingly powerful force.

Almost everyone's seen or heard a traumatic vaginal delivery 'horror story', and it is only a matter of time before women realise that they see and hear far fewer horror stories that relate to a woman who chose and planned a cesarean delivery.