The True Cost of a Cesarean

….may never be known.

There are so many different factors — some financial, some health-related, some emotional. While not everyone agrees with this, many studies show a higher death rate for both mothers and babies with a C-section. Some C-sections are done for failed inductions; and the inductions failed because the babies weren’t ready, and many times have to spend extra time in the NICU. Many mothers are left with sadness regarding their surgeries and feel as if their bodies let them down. But here are some real stories I am acquainted with, that each show that in some ways, the C-section isn’t the end — its effects may continue to be felt for years.

1. A life-long friend had a C-section a year ago when her baby was transverse and her water broke. It was an uncomplicated C-section, and she didn’t even stay in the hospital a full 48 hours. Her bill was $25,000. This greatly surprised me because I assumed that an uncomplicated C-section would be more in the $15,000 range. While her insurance covered 80%, their portion was still $5,000. Ouch! Even worse, her recovery was so bad (couldn’t get out of bed or a chair by herself for 3 weeks), that she told me that she wouldn’t have any more children if she knew she’d have to have another C-section.

2. Someone whose blog I keep up with is currently having secondary infertility, probably due to her C-section a few years ago. In addition to the emotional toll of having multiple miscarriages, there is the added burden of going through tests (some of them expensive, some not covered by insurance), to try to find the cause of her inability to carry another child to term.

3. Another person whose blog I keep up with is currently in the midst of a (hopefully) 12-week hospital stay. She has placenta previa, which can happen even in an unscarred uterus, but is more likely to happen if you’ve had a C-section before. She was put on hospital bed-rest after having a few episodes of slight vaginal bleeding. She’s hoping to get to 36 weeks, at which point they’ll take the baby by C-section. But it’s possible that she may dilate too much before then, and they’ll have to take the baby prematurely. Now, I don’t know what the cost of her hospital stay is, but for 84 days of hospital care, and the frequent (sometimes constant) monitoring that she is undergoing cannot be cheap. Then there is the emotional toll of being in the hospital, away from her husband and daughter, and worrying or at least wondering about the health of her baby, and hoping that she’ll be able to remain pregnant long enough that he won’t have to stay extra time in the NICU.

When C-sections save lives, that’s one thing. But there is a current article promoting Cesareans on demand. It just makes no sense to me, but maybe it does to some people. Then there are all the C-sections that are made necessary because of “the cascade of interventions” that so frequently happens in a hospital setting.

In light of the long-term downsides of a C-section, just make sure the cost of a C-section is worth what you’re going to have to pay.

Should men attend the birth of their baby?

There was this article that has recently been printed in which Dr. Michel Odent, world-famous obstetrician, says that he has long thought that men hinder the birth process. One of my fellow independent childbirth members emailed him directly, and he said that the article was not written by him, but by a journalist after a telephone interview, and that he has never said that men “should not be at the birth of their child.” Still, it opens up an avenue of thinking and questioning for me.

First, my personal experience — I was glad that my husband was there with me when our first child was born, but he didn’t really help that much; the midwife and doula were much better at the whole “labor thing” (which stands to reason, since it is their job and calling, and what they do all the time, while it was the first time for my husband). It is one of my biggest regrets that my husband missed the birth of our second child, being out of town and unable to make it back in time.

When I’ve posed this question or made a statement along this line in my birth-related email groups, there have generally been two types of response: 1) women who gush about their husbands and say that they couldn’t have done it without them; and 2) women who have the same thoughts as me — that men are not really that beneficial at a birth.

There are some men who should not be at a birth. I’ve recently read a blog post in which a woman said that although she felt like she was handling labor fine, her husband talked her into getting a C-section because he couldn’t stand seeing her in pain. (I guess that a C-section recovery isn’t painful?) One of my brothers-in-law watched TV the whole time my sister was in labor, and was glad when she got an epidural so he wouldn’t have to listen to her vocalize during contractions. I’m not saying that these types of men are hopeless causes, but that if they’re not willing to be supportive of their wives during labor, then why should they be there at all?

Back in the 50s, it was taken for granted that the father’s “place” in labor was pacing in the waiting room. Then came the “natural childbirth” revolution of the 70s and the pendulum quickly swung to where it was taken for granted that the father’s place in labor was to be right by the mother’s side as a labor coach. I will posit that neither of these extremes is totally accurate or healthy. Most men fall somewhere in the middle.

Some men may start out having to be coerced to attend the birth of their baby, and then be ecstatic when they are there to witness the birth. Other men may not even entertain a thought of not being there, but be disturbed by what actually happens at birth. (There may be sexual side effects either from seeing the birth itself, or having so many strangers touch his wife’s genitals, etc. It may be disturbing to many men to see their wives in pain yet be unable to stop it — they may even feel guilty for getting them pregnant in the first place. Some birth attendants may be rude or unfeeling, and leave the man feeling like he should have done something, but didn’t know what.)

While having your husband at the birth may be the best thing to happen, it would be extremely beneficial to have certain things ironed out beforehand, to make sure you’re both on the same page. Men are different from women. I think it’s an extremely important fact that for all of recorded history, up until fairly recently, childbirth was “women’s business,” and the usual order of things in almost every society in the world was to have other women attending the laboring mother. Sometimes the father of the baby was there, but this is the exception to the rule. Don’t expect a man to act like a woman. Hire a doula or a midwife if you want the unique benefits that a woman offers. Men can be wonderful — may even be surprising!

Case in point — a friend of mine realized that her husband would not be the kind of man to support her in labor as she felt like she needed to be supported. On one of the long drives back from a childbirth class, she had the painful discussion with him, and basically let him off the hook, and mentally lowered her standards of what she expected from him. In labor he was “P-E-R-F-E-C-T” she said — he read her cues, did what she wanted without asking, etc. Perhaps it was that he was able to relax, and feel like he wasn’t being held to an impossibly high standard. Perhaps he just wanted to prove her wrong.

Childbirth is an amazing, life-changing time — for both mother and father. While I think it is unfair to bar all men from attending the births of their children, I think it equally unfair to mandate all men to attend the births of their children. Think about it. Ask him what he wants. Ask yourself what you want. Have the difficult discussion with him if necessary. Hire a doula as a labor support — both for you and for him — having a knowledgeable and well-trained person to “fall back on” or suggest helpful things can ease the pressure. And be realistic about your husband’s personality. Don’t try to force your husband to become a perfect female labor companion. Men are different from women. Enjoy that! And be realistic.

For another perspective, click here.

Checking dilation without a vaginal exam

Yeah, this piqued my interest, too.

First, there are many reasons why it would be beneficial or helpful or preferable to be able to check your progress without having a vaginal exam. The most obvious is the discomfort of having someone (as I read on another blog) “search for my tonsils via my lady parts.” Also, vaginal exams increase the risk of infection if the water has broken — even when sterile gloves are used, there are bacteria on your body that get on the sterile gloves and then are given a free ride up to your cervix. Before sanitation (even simple hand-washing) was practiced by birth attendants, it was common for women to die of “childbed fever” due to germs being introduced directly into the uterus this way.

[As an aside, when you hear people decry modern homebirth because "women used to die all the time before they started having their babies in the hospital," you now know that the high maternal death rate was at least partially attributable to doctors' dirty hands infecting scores of women. It was common practice to teach medical students how to do vaginal exams by using cadavers -- dead women (who frequently were victims of childbed fever) -- and then to go down the hall to where women were laboring and without washing their hands, perform vaginal exams on them, directly introducing the germs from a dead person into the body of a living person.]

But another reason would be to assess where you are in your dilation so that you know when to go to the hospital (if you’re planning a hospital birth). A frequent concern of women is that they’ll go to the hospital (or call the midwife) too soon…. or else too late. In the first case, they may be turned away until they are dilated more; and in the second case, they may have a harrowing ride to the hospital with a white-knuckled husband fighting his way through traffic while she tries not to push.

On this thread at Midwifery and More, there are a few different ways mentioned, but the one I want to talk about most is one that Anne Frye wrote about in Holistic Midwifery, Vol. II, p. 376. Sarah Wallbaum mentioned it on our childbirth educators email list, and it intrigued me. Here’s how it works:

During a contraction and with mom on her back, determine how many fingerbreadths of space are between the fundus [top of the uterus] and xiphoid process [the triangular tip of the breastbone] at the height of a contraction.

5 fb = no dilation
4 fb = 2 cm
3 fb = 4 cm
2 fb = 6 cm
1 fb = 8 cm
0 fb = complete

She said that she has practiced this for accuracy with a midwife, and has both found it to be fairly accurate, but that if a mom is very obese, it would be difficult to use. Even if it just gives a “ballpark figure” it just feels empowering to me to be able to know this information without having somebody else’s hand stuck up inside me. Remember also, that the World Health Organization’s guidelines for Safe Motherhood says that vaginal exams should be kept to a strict minimum, and in the first stage of labor once every four hours should be enough (3.3).

Update: Here is another blog post that has other ways of checking dilation.

Updated again to add this link to an image of the xiphoid process method of estimating dilation.

And yet another update (7/27/10) for this link

Updated again to add this abstract (9/24/10): a study on the colored line that usually appears between a woman’s buttocks as she dilates

It might have happened — what then?

Women are often told not to eat when they’re in labor. In fact, I heard one story in which a woman was having some early labor, and called the hospital to see if it was “real labor” or not, and while they didn’t say that it was or wasn’t, they told her that if she thought she was in labor not to eat. It was Thanksgiving Day. She had looked forward to the sumptuous spread all year, and she had to spend the day smelling the delicious food being prepared, but was not allowed to eat a bite. Why?

The rationale is that you might need general anesthesia at some point (for an emergency C-section and/or hysterectomy), and you might vomit the contents of your stomach when you’re unconscious, and it might be inhaled, and it might cause aspiration pneumonia or even death. The risk is slight, but real. A relative of a friend died because of this several years ago, when she had a tonsillectomy. They have anesthesia procedures that when followed properly almost entirely eliminate this possibility, but doctors are human too so there is always a tiny possibility that something could go wrong.

According to this article, the likelihood of a first-time mom giving birth vaginally having a hysterectomy is 1 in 30,000, but the risk increases dramatically if you’ve had a prior C-section. Emergency hysterectomies are usually performed for uncontrolled bleeding after birth, if other measures to stop the bleeding have failed. Obviously, it’s rare. Up to 30% of U.S. women now give birth via abdominal surgery, but C-sections under general anesthesia are rare, because even most unplanned C-sections are not true emergencies, and there is time to place or strengthen epidural anesthesia. So, the likelihood of you needing general anesthesia is very slight. Also, according to Henci Goer’s The Thinking Woman’s Guide to a Better Birth, p. 77, studies show that “no time interval since the last oral intake guarantees a stomach volume below [25 ml -- the "threshold of risk"] in a pregnant woman. In fact, no time interval guarantees a volume of less than 100 ml.”

Now on to the “what if.”

When I had my first baby, my water broke before I had any contractions. There was no warning that labor was going to start that day, as opposed to a week before. Although I was very tired of being pregnant, there was no way to know when labor would begin–it was just “business as usual.” So, that night we ordered in Chinese, and I ate my fill. About an hour or so later, my water broke.

The umbilical cord, of course, did not prolapse, and I went on to have a normal and completely unmedicated birth, but what if it had? What if I had needed an emergency C-section? My stomach was extremely full — what then? Simple — the anesthesiologist would just need to follow modern standard anesthesia techniques, stick a tube down my throat to maintain my airway so that even if I vomited, I could not inhale it.

Anesthesiologists have to deal with this all the time. Do you think that every person who needs emergency surgery — victims of heart attacks, strokes, car wrecks, skiing accidents, etc. — has an empty stomach?

When there is a scheduled surgery under general anesthesia, it makes sense to try to minimize the risk by fasting for a few hours beforehand, even as slight as the risk already is. But for a 1/30,000 chance that you might need general anesthesia? And since a lot of C-sections are done because mothers are just too exhausted to go on, quite possibly because they haven’t eaten in several hours and their energy stores are depleted, doesn’t it make more sense to let women eat in labor if they wish so that they can withstand the hard work of bringing forth their babies?

And if you don’t believe me…

…then check out this article by a former L&D nurse. (Be sure to click “next” which is on the left-hand side of the screen to read the next page of the article.)

She talks about (among other things) why you can’t eat or drink in labor; the downsides of epidurals; why doctors are so quick to call for a C-section; that doctors aren’t trained to attend vaginal breech births; that (in fact) doctors aren’t trained to do a lot of things any more, because they are trained to rely on machines and medicine; giving medicine via IV without the woman’s knowledge or consent; the use of Cytotec; and hospital-acquired infections.

Suspected big baby?

What would you do if an ultrasound shows that your baby is big? Many women have to answer that question for themselves. Their options are to plan a C-section, get induced before the baby gets any bigger, or do nothing and wait for labor to begin whenever their bodies and their babies are ready. Some women have extenuating circumstances that muddy the waters a bit, or cause them to have to make other decisions — for instance, some women are “risked out” of a planned home birth because of suspected big baby (macrosomia); others may not be allowed to have a VBAC (that is, if you can find a supportive hospital or doctor any more).

The first question I ask is, “How accurate is the fetal weight estimate, anyway?” Notoriously wrong, actually. Most estimated fetal weights are within 10% of the actual weight. That sounds pretty good. Unfortunately, that’s about a pound or a pound and a half off. This means that if your baby is estimated to weigh 7 &1/2 pounds, it could actually weigh anywhere from 6 to 9 pounds, according to this margin of error. And not all estimated fetal weights are within that 10% margin of error, either. Here is a wonderful link about suspected macrosomia, with a lot of birth stories about inaccurate estimated fetal weight. The stories include just about every variation you can think of — babies that were supposed to be normal weight, but — surprise! — they were actually “macrosomic” (but still completely normal); babies that were supposedly macrosomic, and the mothers had C-sections, or were induced, and — surprise! — they were actually normal weight, or even a bit on the small side. In Henci Goer’s book The Thinking Woman’s Guide to a Better Birth, she notes that when doctors think that a baby is big, they are more likely to intervene or call for a C-section (even when the baby’s actual birthweight is not “too big”), but when doctors think that a baby is not big, they don’t intervene, even when the baby’s actual birthweight is “macrosomic.”

Here are a few other links that I thought were interesting. This is a collection of links regarding various aspects surrounding macrosomia (inductions, C-sections, Apgar scores, shoulder dystocia, etc.). Here is an article discussing cephalopelvic disproportion (CPD), which is the typical reason given when women have C-sections for big babies. An article that appeared in the AAFP Journal concluded that pregnancies with suspected macrosomia should be handled “expectantly” and that interventions should only be used if labor does not progress as expected. It also includes a table with risk factors for macrosomia. This article by the National Institute of Health concludes “The best policy is to await spontaneous birth or to induce labor after 42 weeks completion.” And finally is a webpage that includes a lot of information about macrosomia, but I especially wanted to include it because of the “Big Baby Birth Stories” — most of these babies are in the 9 lb. range, but there are a few that were 11 lb. or more.

As far as personal experience goes, I’ve had one ultrasound, which was done late in my first pregnancy because the midwife thought she might have heard two heart-beats at the prenatal visit; the estimated fetal weight was 7 lb. 8 oz. When my baby was born 10 days later, his actual weight was 7 lb. 5 oz. (3 oz. less than the ultrasound estimate, at a time when babies gain about half a pound a week average). It was nearly 1 lb. off. One of my sisters-in-law had IUGR with her 2nd baby, so they kept close watch on her 3rd baby. A few days before she was born, they estimated her fetal weight as “lucky to be 6 pounds.” She was over 8 lb. (They had a hard time seeing anything of the baby because of the way she was positioned.)

My second son was 9 lb. 2 oz. My sisters’ sons (their 2nd babies) were both over 9 lb. (and we didn’t tear). Another sister-in-law’s first baby was 9 lb. 8 oz. (after pooping and peeing), and she didn’t tear at all, which is important to note because some people will say that “every woman tears when she gives birth to her first baby” and others will say that “all women tear if their babies are big.”

Ergonomics in Birth

Some years ago, “ergonomics” was all the rage — ergonomic chairs, ergonomic keyboards, even ergonomic juice bottles became permanent additions to our lives. (I still have and love my ergonomic keyboard!) The term comes from two Greek words meaning “work” and “natural laws.” The idea is to minimize what the joints and muscles have to do in order for you to perform a particular action, and thereby to reduce the strain on the body. Of course, I had to relate this to birth — after all, here, as nowhere else, are “natural laws” relating to “work” or “labor.”

This is an interesting article on ergonomics. It mentions how that deer instinctively move in “the most efficient way possible,” but that humans are not that way, because we don’t operate on instincts. We observe others, we develop habits, and we learn how to move — in ways that may not be “natural,” “instinctive,” or “the most efficient way possible.” The author says, “We mistake ‘habitual’ for ‘natural.’”

I thought these two paragraphs were especially good as relates to birth (although that is not the intent of the author):

To truly improve the way we move, it is necessary to step back and question our assumptions about what is “natural”. Sometimes learning about the mechanics of body movement (“Here is where your leg bends, here is where your lungs are,”) can make a big difference. Sometimes watching a movement in the mirror can provide surprising new information. (“I had no idea I was doing that!”) And sometimes a quiet hand on the shoulder can help us become aware of excess tension.

When we learn to recognize our habits and to stop doing them, we can recover a more natural, easy, and pleasant way of moving. We become better able to notice when a work situation is set up poorly, and we are more likely to benefit from ergonomic aids. Moving in a more efficient manner, learning new skills becomes easier, and old skills can become more refined.

Starting with the first sentence, let’s question the assumptions about what is “natural” in birth. What do movies and television shows portray? Women lying in beds, typically on their backs, with monitors strapped to their bellies, one arm in a blood-pressure cuff, the other arm (or hand) with an IV in it. That’s what the typical “woman in labor” looks like. Fast-forward to birth and what do you see? Women still in bed, although the bed may be in different positions; their feet may be in stirrups; they may be flat on their backs, although it is more typical in modern U.S. hospitals to have the upper body raised. Many times women are in a “C” position — sitting on their tailbones, hunched over — and frequently someone is holding their legs up, with their knees pushed up towards their ears. It always gets me when they tell the woman to “hold your legs like you’re squatting” while she’s on her back. I wonder, “if squatting is so good, then why not just let her get up and squat?!”

But this is not natural. It’s not instinctive. And it’s certainly not the most efficient way! It’s habitual, and the woman-in-bed position started to give doctors a good view of her genitals, and for their ease of access, and so they wouldn’t have to squat down and demean themselves by being lower or beneath a woman. You can go to YouTube and look at just about any home birth video and contrast it to any hospital birth video, and you’ll see what I mean. Most midwives who attend home births consider it as part and parcel of attending births to adapt to what the woman needs — for the midwife to change positions so that the mother doesn’t have to; to get on the floor so the mother can remain comfortable; to squat or kneel and work by touch, so that the mother doesn’t have to get into the “stranded beetle” position just so the birth attendant can get a good look. Home birth is set up to accommodate the laboring and birthing woman; hospital birth is set up to accommodate the labor and delivery nurses and doctors.

Midwives encourage women to follow their instincts and assume natural laboring and birthing positions. Here is what is important — what works for one woman may not work for another; what works at one point in labor may not be beneficial at another time. Women are different; babies are different. Also, the position the baby is in (facing the mother’s belly, side or back), the stage of labor, and the woman’s preferences greatly affect what is comfortable for her, and what is conducive to labor.

Now, on to the second point of the above-quoted paragraphs: the mechanics of body movement. Squatting is a wonderful position for birthing a baby. Not only does it allow gravity to help, but it allows the tailbone to naturally flex outward while the baby’s head moves past it, and it opens up the pelvis allowing the baby to more easily move down. Lying on your back actually requires you to work against gravity, because you have to push your baby up and over the coccyx. (Here are a couple of videos that show this.) While being in the “C” position (basically sitting on your tailbone, instead of lying on your back) helps a bit because you are able to muster more of your muscles for pushing (imagine having a bowel movement on your back, versus on a toilet), you are actually preventing the tailbone from moving, which narrows the outlet through which the baby must pass. A friend of mine broke her tailbone this way. Her epidural had so numbed her that she couldn’t feel what was a good position to be in; and she didn’t feel it when it happened, but she was miserable for months afterwards if she tried to sit for any length of time.

Here are some more links to posts about pushing that I really enjoyed: Bringing Baby Forth During Childbirth at Birthing Touch, and Upright Birth in Hospitals and Lie Down and PUSH at The True Face of Birth.

Perhaps they will help you (paraphrasing the above quote) to “recover a more natural, easy, and pleasant way of birthing. You can become better able to notice when a labor or birth situation is set up poorly, and you are more likely to benefit from ergonomic positions. Laboring in a more efficient manner, using new skills becomes easier, and old skills can become more refined.”

Breech birth video!

This video is awesome. It’s from Australia, and the woman gives birth to a baby in the footling breech position (the baby’s feet present first, as opposed to the buttocks which is the most common breech position).

My thanks to Rixa for posting this link on her blog.

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The Best-Kept Secret

“What would happen if women were taught to enjoy birth rather than endure it?” poses the website Orgasmic Birth. The answer lies in the film of the same name, which follows eleven women as they give birth.

Think orgasmic or ecstatic birth is impossible? I know that birth can be empowering. On another blog I read in the past (and can’t recall where!), the author likened sex to birth in this way:

Is sex painful? Most women will say no. But all women will recognize that sex is painful or distasteful or otherwise negative for some women. In like manner, birth is painful, distasteful, or otherwise negative for most women, but for some it is not painful, it is pleasurable, and completely positive.

Think about it — if sex can be unpleasant or downright painful for some women but not for all, why then cannot birth be the same? There are many reasons why some women will not like sex; ditto for birth. But if you were talking to a woman who found sex painful, while you found it pleasurable, would you not want to give her tips or information on making sex better for her — enjoyable, even? So if a woman found birth orgasmic and wanted to share with you how that happened, wouldn’t you want her to share that information?

A near-death experience, courtesy of Cytotec

When independent childbirth educator Nicole D. was pregnant with her first child, she consented to an induction when she went nearly two weeks past her due date. Although she said she was “naive and unprepared,” she did know that she most certainly did not want Cytotec (a.k.a. “misoprostol”, “miso” or “the little white pill”) used on her. Her doctor was in agreement with her, saying he never used it. Unfortunately, the doctor who was at the hospital when she went in to be induced did use it — against her express wishes, and without informing her that he had done so.

Read the rest of her story here.

For more information about Cytotec, please visit the Tatia Oden French Memorial website. Tatia Oden French was induced with Cytotec when she went past her due date, and both she and her baby died. Her mother vowed, “That drug is going to go away.” You can read more about her efforts here.